Needs Analysis- Medicare

Needs Analysis for New Medicare Beneficiaries

Providing this information is completely voluntary and not a requirement. Information collected is used to help identify any current and future needs for your medical and financial situation. All information recorded is completely confidential.

Client Name

Todays Date:

Date

Date of Birth*

Date

Email Address:

Address:*

Phone Number:*

Medicare Number

Part A Date

Date

Part B Date*

Date

Do you qualify for Medicaid?

NoYes

Medicaid Number

Does anyone else in your household need health insurance:

NoYes, If yes please complete a needs analysis for them also.

Do you prefer either of the following?

Medicare Advantage PlanMedicare Supplement & Prescription Drug Plan

Type of current healthcare plan:

Some People who have certain Chronic Medical Conditions qualify for a Special Medicare Advantage Plan Call C-SNP. Do you want me to see if you qualify for any of these plans?

YesNo

Have you been Diagnosed with Diabetes, Chronic Heart Failure, or a Cardiovascular disorder?

YesNo

Primary Care Doctor:

Name of Specialist Name Specialty Specialty .

Preferred Hospital:

Do you have any medical conditions that should be considered when looking for a healthcare plan for you?

Do you have any expected medical procedures planned?

Do you have any additional services required? (ie, physical therapy, mental health, chiropractic care)

Do you want vision coverage?

YesNo

Do you wear glasses?

YesNoMaybe

Do you get routine dental exams?

NoYes

Name of your Dentist

Do you need any major dental work done (ie, dentures, bridges, extractions)?

Are you on any Prescriptions?*

YesNo

Preferred Pharmacy

Prescription Name Prescription Name . Dosage Dosage mg. Tablet or Capsule Tablet or Capsule . Quantity per Month Qty per Month

Any other information that would be helpful for us to find you a Healthcare Plan