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Please Contact Me About Medicare Plans.
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County
Phone Number
Please enter a valid phone number.
Email
example@example.com
Signature
Today’s Date
-
Month
-
Day
Year
Date
Back
Next
NEADS Analysis
Medicare #
Part A Effective Date
Part B Effective Date
Do you receive Medicaid or any extra help?
Yes
No
Do you currently receive any extra help services? If so, please check all that apply.
Medicaid
Extra Help w/ Part D from Social Security (LIS)
None
Medicaid #
LIS Percentage
Current Plan
What is your total monthly income?
What is your annual income?
Do you make less than $20,000 a year?
Yes
No
Do you currently receive any other health insurance through a former employer or organization? (Ex. Spouse’s plan, Retirement, VA, Tricare, etc.)
Yes
No
If yes, please provide name of company, sponsor name, policy number, and a company contact number. (This is for the purpose of verifying if they coordinate benefits with Medicare or not.)
What extra benefit would you say you need? (What’s most important to you, check all that apply.)
Dental
Dental Implants
Vision
Hearing
Hearing Aids
OTC over-the-counter items
Are there any extra benefit(s) you need or would like to have? Check all that apply.
Dental
Dental Implants
Vision
Hearing
Hearing Aids
OTC over-the-counter items / Heathy Foods
Do you have (check all that apply)
Diabetes
Heart/Cardiovascular Disorders
ESRD or on Dialysis
None
Do you want any prescriptions checked against the formulary? If so, list all prescription medications (Include name, dosage, quantity, and frequency taken.)
How much do you pay for your prescriptions?
Do you have a preferred pharmacy? If so, please list the name and location here.
Do you have a particular doctor or specialist you like to use? If so, List the names of your doctors (PCP, specialists, dentist, etc.)
Last Name, First Name
Notes
File Upload (Upload a photo of your Medicare, Medicaid, and/or other health insurance card.)
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