Medicare Questionnaire
Disclaimer: A sales agent may mail, call or e-mail as a result of completing the information to discuss Medicare Advantage, Prescription Drug Plans or Medicare Supplement Insurance. Note that red asterisks within this form are required. Further, you are not required to provide us with information that is labeled optional.
Full Name
*
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
*
-
Country Code
-
Area Code
Phone Number
Email Address
*
example@example.com
Physical Address (US)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address (if applicable)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Medicare #
Optional Additional Information
Please select the following items that apply to you:
Yes
No
Do you have a group health plan?
Do you qualify for Medicaid?
Do you qualify for Extra Help?
Do you have a Medicare Supplement or Medicare Advantage Plan?
(Provide details on the space above.)
Do you have a stand alone Part D Plan?
(Provide details on the space above.)
What would you like to change about your current Medicare plan or Drug plan?
(Provide details on the space above.)
What prescriptions (not OTC) do you take regularly (include dosage/frequency)?
Name
Dosage
Frequency
30 or 90 day refill
1
2
3
4
5
6
7
8
9
10
What is your primary pharmacy and address?
(Provide details on the space above.)
What doctors do you see on a regular basis?
(Provide details on the space above.)
Medicare Card Photo Upload
Please upload a copy of your Medicare Card (red, white, and blue).
File Upload
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