Medicare Consultation Preparation Form
Information provided will not be shared with any 3rd parties
Please complete the questions on this form with as much detail and accuracy as possible.
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Home Address (physical address - no PO Box)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you have a separate mailing address?
No
Yes
Mailing Address (PO Box is allowed)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How Did You Hear About Us?
*
Personal Email
*
example@example.com
Preferred Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Do You Currently Have Health Insurance?
*
No
Yes
Current Health Insurance Type
*
Job-based health insurance
Private pay health insurance
Medicare
Name of Employer Providing Your Current Health Insurance
Name of Current Insurance Company
Your health insurance ID number
Date New Medicare Coverage is Needed
*
-
Month
-
Day
Year
Date
Back
Next
Are You Enrolled in Medicare?
*
No
Yes
Medicare ID Number (if already enrolled in Medicare)
Medicare Part A Effective Date (check your Medicare card)
-
Month
-
Day
Year
Date
Medicare Part B Effective Date (if enrolled - check your Medicare card)
-
Month
-
Day
Year
Date
Do You Take Prescription Medications Currently?
*
No
Yes
Submit
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