Client Medicare Needs Analysis

Confidential Needs Analysis

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Fields with an asterisk are required.

By completing this form and providing my email address or telephone number, I agree to allow a licensed sales representative from Insurance All-Stars to contact me regarding information related to Medicare health plans and health insurance plans, products, services and/or educational information related to health care. I also understand that the person who will be discussing plan options with me may be compensated based on my enrollment in a plan, if I choose to enroll.
Date

MonthDayYear
Date
Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
What county do you live in? If you own your home, what county do you pay taxes to?*
Date of Birth

MonthDayYear
Date
Birth Gender

FemaleMale
Are you a Veteran?

YesNo
Do you primarily use the VA?

YesNo
Do you make your own healthcare and financial decisions?

YesNo
Are you married?

YesNo
Will Spouse be looking for coverage as well?

YesNo
Spouse's Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Birth Gender

FemaleMale
Is Spouse a Veteran?

YesNo
Does Spouse primarily use the VA?

YesNo
Does Spouse make their own healthcare and financial decisions?

YesNo
Are you a snowbird or a person who travels often?*

SelfSpouseSelf and SpouseNo
Do you work?

SelfSpouseSelf and SpouseNo
What is your expected retirement date?
What is Spouse's expected retirement date?
Do you currently have health coverage?

SelfSpouseSelf and SpouseNo
Who is your coverage through?
Who is Spouse's coverage through?
Do you currently have Medicaid? (This would be through the State—for example, Florida.)

SelfSpouseSelf and SpouseUnsureNo
Are there any companies that you refuse to have coverage through?

YesNo
Which one(s)
Which type of coverage are you looking for? Choose all that apply.

Medicare Advantage HMO $ - This coverage will give you the ability to see any doctors within the network of the insurance provider you choose (usually) after an approved referral from your assigned primary care doctor. This coverage can include prescriptions, and usually provides more dental, vision, hearing and many times extra benefits. You may purchase an additional dental, vision, hearing plan with this coverage.Medicare Advantage PPO - $$ This coverage will give you the ability to see any doctor in the country who will accept the plan, with no referrals required (unless it's a particular office's procedure). There may be different costs for in-network providers vs out-of-network. This coverage can include prescriptions, and usually provides limited dental, vision, hearing and sometimes extra benefits. You may purchase an additional dental, vision, hearing plan with this coverage.Medigap - $$$ This will give you the ability to see any doctor in the country who accepts Original Medicare with no network restrictions and no referrals required (unless it's a particular office's procedure). Many have said this is the easiest coverage to deal with, although costly. Does not include prescriptions or dental, vision, hearing but you may purchase an additional plan for those.Not sure
Which type of coverage are you looking for? Choose all that apply.

Medicare Advantage HMO $ - This coverage will give you the ability to see any doctors within the network of the insurance provider you choose (usually) after an approved referral from your assigned primary care doctor. This coverage can include prescriptions, and usually provides more dental, vision, hearing and many times extra benefits. You may purchase an additional dental, vision, hearing plan with this coverage.Medicare Advantage PPO - $$ This coverage will give you the ability to see any doctor in the country who will accept the plan, with no referrals required (unless it's a particular office's procedure). There may be different costs for in-network providers vs out-of-network. This coverage can include prescriptions, and usually provides limited dental, vision, hearing and sometimes extra benefits. You may purchase an additional dental, vision, hearing plan with this coverage.Medigap - $$$ This will give you the ability to see any doctor in the country who accepts Original Medicare with no network restrictions and no referrals required (unless it's a particular office's procedure). Many have said this is the easiest coverage to deal with, although costly. Does not include prescriptions or dental, vision, hearing but you may purchase an additional plan for those.Not sure
Will you rely on plan transportation?*

SelfSpouseSelf and SpouseNo
How many trips will you need?

0-1010-2020+
How many trips will Spouse need?

0-1010-2020+
Some plans are designed for Medicare beneficiaries who have a qualified chronic condition. To qualify, you must be diagnosed with chronic heart failure CHF, cardiovascular disease CVD, diabetes, or certain breathing conditions such as COPD. These plans may offer extra benefits and savings. If you feel that you may qualify and would like to share that information, please choose all that may apply.

Chronic Heart FailureCardioVascular DiseaseDiabetesCOPDNot sureNo ConditionsDecline to answer
SPOUSE: Some plans are designed for Medicare beneficiaries who have a qualified chronic condition. To qualify, you must be diagnosed with chronic heart failure CHF, cardiovascular disease CVD, diabetes, or certain breathing conditions such as COPD. These plans may offer extra benefits and savings. If you feel that you may qualify and would like to share that information, please choose all that may apply.

Chronic Heart FailureCardioVascular DiseaseDiabetesCOPDNot sureNo ConditionsDecline to answer
Does your family have a history of cancer?

SelfSpouseSelf and SpouseNo
Do you use any Durable Medical Equipment such as an insulin pump, oxygen machine, CPAP etc?*

SelfSpouseSelf and SpouseNo
Do you pay a monthly rental fee for any Durable Medical Equipment?

SelfSpouseSelf and SpouseNo
Do you have any surgeries or other important doctor appointments currently scheduled?*

SelfSpouseSelf and SpouseNo
What type and when?
What type and when for Spouse?
What hospital do you need in network? This would be for surgeries or other procedures, not emergencies. If you have no preference, please type ANY.*
What hospital does spouse need in network? This would be for surgeries or other procedures, not emergencies. If you have no preference, please type ANY.*
Where will you receive care in the event you need someone to permanently bathe you, feed you, dress you, help you from the bed or chair, lose your memory etc?

In-homeFacilityNot sure
Who will help you?
Where will the Surviving Spouse receive care in the event they need someone to permanently bathe them, feed them, dress them, help them from the bed or chair, lose their memory etc?

In-homeFacilityNot sure
Who will help them?
Do you have a long-term care plan to help with costs?

SelfSpouseSelf and SpouseNo
Do you have savings, LTC plans, or other monies to help with these costs and other costs your health insurance doesn't cover?

YesNo
About how much do you have in savings?
Will you depend on Medicaid to cover these costs?

SelfSpouseSelf and SpouseNo
Do you own your home?

YesNo
Do you still have a mortgage?

YesNo
Do you have life insurance?

SelfSpouseSelf and SpouseNo
Is this for burial/cremation?

YesNo
Is Spouse's for burial/cremation?

YesNo
Do you receive Social Security?

SelfSpouseSelf and SpouseNo
How much do you receive in Social Security?
Do you receive any additional income?

YesNo
Do you and/or Spouse receive any additional income?

SelfSpouseSelf and SpouseNo
What is the estimated value?
Do you have a guarantee that your money will never run out, even if you live forever?

YesNo
How much does Spouse receive in Social Security?
Does Spouse receive any additional income?

YesNo
What is the estimated value?
Do you have a plan in place for continued income for the Surviving Spouse? Married couples will lose one Social Security income in the event of a spousal death.

YesNo
Does Spouse have a guarantee that their money will never run out, even if they live forever?

YesNo
Do you have any concerns related to healthcare and personal finances?
Do you have a financial advisor who helps you?

YesNo
Doctors, Specialists, and other providers

Please list any doctors and medical facilities you will need to keep seeing. These would include your specialists, dentist, vision providers, durable medical equipment companies, imaging centers, etc. Include first and last name if possible, what type of specialist they are, what city they are located in, and specify if they are mandatory to keep or not. We will do our best to find a plan that all accept. If you have a list available, please feel free to attach it in an email or text message or upload a copy at the end of this form.
Primary Care Physician*

Name of PhysicianType of doctorCity the office you visit is locatedMandatory Y or N
Spouse Primary Care Physician*

Name of PhysicianType of doctorCity the office you visit is locatedMandatory Y or N
Specialist - If NONE, please type NONE for physician and move on to next section.

Self or SpouseName of PhysicianType of doctorCity the office you visit is locatedMandatory Y or N
Specialist

Self or SpouseName of PhysicianType of doctorCity the office you visit is locatedMandatory Y or N
Specialist

Self or SpouseName of PhysicianType of doctorCity the office you visit is locatedMandatory Y or N
Do you have more Specialists?

YesNo
Specialist

Self or SpouseName of PhysicianType of doctorCity the office you visit is locatedMandatory Y or N
Specialist

Self or SpouseName of PhysicianType of doctorCity the office you visit is locatedMandatory Y or N
Specialist

Self or SpouseName of PhysicianType of doctorCity the office you visit is locatedMandatory Y or N
Do you have more Specialists?

YesNo
Specialist

Self or SpouseName of PhysicianType of doctorCity the office you visit is locatedMandatory Y or N
Specialist

Self or SpouseName of PhysicianType of doctorCity the office you visit is locatedMandatory Y or N
Specialist

Self or SpouseName of PhysicianType of doctorCity the office you visit is locatedMandatory Y or N
Do you have more Specialists?

YesNo
Specialist

Self or SpouseName of PhysicianType of doctorCity the office you visit is locatedMandatory Y or N
Specialist

Self or SpouseName of PhysicianType of doctorCity the office you visit is locatedMandatory Y or N
Specialist

Self or SpouseName of PhysicianType of doctorCity the office you visit is locatedMandatory Y or N
Do you have more Specialists?

YesNo
Please fill in the rest here.
Prescriptions

Are you currently taking any prescriptions? Please list and include the name, dosage, and form—such as tablet, capsule, solution, cream, inhaler, etc. If you have a list available, please feel free to attach it in an email or text message or upload a copy at the end of this form.
Prescription - If NONE, please type NONE for drug and move on to next section.

Self or SpouseName of drugDosage and form - Is this a tablet, capsule, solution, cream, inhaler, etc
Prescription

Self or SpouseName of drugDosage and form - Is this a tablet, capsule, solution, cream, inhaler, etc
Prescription

Self or SpouseName of drugDosage and form - Is this a tablet, capsule, solution, cream, inhaler, etc
Prescription

Self or SpouseName of drugDosage and form - Is this a tablet, capsule, solution, cream, inhaler, etc
Prescription

Self or SpouseName of drugDosage and form - Is this a tablet, capsule, solution, cream, inhaler, etc
Do you have more prescriptions?

YesNo
Prescription

Self or SpouseName of drugDosage and form - Is this a tablet, capsule, solution, cream, inhaler, etc
Prescription

Self or SpouseName of drugDosage and form - Is this a tablet, capsule, solution, cream, inhaler, etc
Prescription

Self or SpouseName of drugDosage and form - Is this a tablet, capsule, solution, cream, inhaler, etc
Prescription

Self or SpouseName of drugDosage and form - Is this a tablet, capsule, solution, cream, inhaler, etc
Prescription

Self or SpouseName of drugDosage and form - Is this a tablet, capsule, solution, cream, inhaler, etc
Do you have more prescriptions?

YesNo
Prescription

Self or SpouseName of drugDosage and form - Is this a tablet, capsule, solution, cream, inhaler, etc
Prescription

Self or SpouseName of drugDosage and form - Is this a tablet, capsule, solution, cream, inhaler, etc
Prescription

Self or SpouseName of drugDosage and form - Is this a tablet, capsule, solution, cream, inhaler, etc
Prescription

Self or SpouseName of drugDosage and form - Is this a tablet, capsule, solution, cream, inhaler, etc
Prescription

Self or SpouseName of drugDosage and form - Is this a tablet, capsule, solution, cream, inhaler, etc
Do you have more prescriptions?

YesNo
Prescription

Self or SpouseName of drugDosage and form - Is this a tablet, capsule, solution, cream, inhaler, etc
Prescription

Self or SpouseName of drugDosage and form - Is this a tablet, capsule, solution, cream, inhaler, etc
Prescription

Self or SpouseName of drugDosage and form - Is this a tablet, capsule, solution, cream, inhaler, etc
Prescription

Self or SpouseName of drugDosage and form - Is this a tablet, capsule, solution, cream, inhaler, etc
Prescription

Self or SpouseName of drugDosage and form - Is this a tablet, capsule, solution, cream, inhaler, etc
Do you have more prescriptions?

YesNo
Please add the remaining prescriptions here.
If you were referred, please list the name of the person who referred you.
Upload your doctor and prescription information here.

Cancelof
Have you completed your Scope of Appointment to discuss exact plan benefits such as copays?*

What is that?Yes I did. Wait.... Did I?Yes, I definitely did.
"Insurance All-Stars are independent insurance agents that do not work directly for the federal government or Medicare. We may or may not offer every plan in your area. We do currently represent 12 organizations which offer 93 products in the Lake, Marion, and Sumter areas where we are primarily located (but are not limited to). Please contact Medicare.gov or 1-800-MEDICARE, or your local State Health Insurance Program to get information on all of your options."
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Confidential Needs Analysis

Fields with an asterisk are required.

Doctors, Specialists, and other providers

Prescriptions