Medicare Needs Analysis

FREE Medicare Needs Analysis

Information provided will be kept confidential and will only be used by a licensed Idaho agent to help locate a plan that fits your particular needs.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Home Address (physical address - no PO Box)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have a separate mailing address?

NoYes
Mailing Address (PO Box is allowed)

Street Address

Street Address Line 2

CityState / 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.
Do You Currently Have Health Insurance?*

NoYes
Current Health Insurance Type*

Job-based health insurancePrivate pay health insuranceMedicare
Date New Medicare Coverage is Needed*

MonthDayYear
Date

Are You Enrolled in Medicare?*

NoYes
If you have Medicare, which of these are you enrolled in? Check all that apply.

Both Part A & BPart A onlyVA (TriCare)State Medicaide
Medicare Part B Effective Date (if enrolled - check your Medicare card)

MonthDayYear
Date
Do you have any chronic health conditions? Check all that apply

DiabetesHeart Failure

	First Name	Last Name	Phone Number
PCP

Extra Help

Some people with limited resources and income also may be able to get Extra Help with the costs (monthly premiums, annual deductibles, and prescription co-payments) related to a Medicare prescription drug plan. To see if you qualify for Extra Help, please visit www.ssa.gov/extrahelp
Would you like more information about applying for Extra Help

NoYes

	Prescription Name (brand required?)	Dosage(cap/tab)	Monthly Quantity	Refill Frequency
Rx 1
Rx 2
Rx 3
Rx 4
Rx 5
Rx 6
Rx 7
Rx 8
Rx 9
Rx 10

FREE Medicare Needs Analysis