Medicare Initial Intake
Getting Started Basic Questions
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Gender:
*
Male
Female
Are You A Smoker:
*
Yes
No
Are you currently enrolled in Medicare?
*
Yes - Have My Number
No - Applied & Waiting
No - Need To Apply
Let's See If You May Be Eligible For Some Carrier Discounts
Are you married?
Yes
No
How Many People Over 18 Live In Your Household?
Helps us see if you qualify for any carrier discounts?
Current Number Of Medications You Take Regularly
A ballpark estimate of how many prescription drugs you are currently taking.
How Would You Describe Your Current Health?
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Medicare Initial Intake
Final Questions
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