MEDICARE INFO
Please fill out all the boxes & submit to complete. Thank you! - George Beach
Name as it appears on your/their Medicare Card (Red, White, and Blue Card - Example Above)
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First Name
Middle Name
Last Name
Suffix
MEDICARE Number (On your Red, White, & Blue Medicare Card - Example Above)
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Hospital (Part A) Date (On your Red, White, & Blue Medicare Card - Example Above)
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Month
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Day
Year
Date
Medical (Part B) Date (On your Red, White, & Blue Medicare Card - Example Above)
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Month
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Day
Year
Date
Are you on State Medicaid? If YES, click & fill in. If NO, skip.
YES
State Medicaid Card Number
Physical Address
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Street Address
Street Address Line 2
City
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State
Zip Code
County
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Do you have a different mailing address? If YES, click & fill in. If NO, skip.
YES
Mailing Address | If applicable, fill in. If not, leave blank
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
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Month
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Day
Year
Date
Landline Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Preferred Number
Landline Phone Number
Cell Phone Number
Do you agree to receive the occasional text message?
Yes
No
Preferred Email Address
Doctor(s) Name & City (Example: Dr. Jack Smith, Modesto, CA)
Prescription Drug(s) - Example: Drug Name: Metformin | Dosage: 10 mg | Quantity Per Month : 30)
Preferred Pharmacy & Address (CVS - 1700 McHenry Ave, Modesto, CA 95350)
Signature | All of the information provided above is accurate as of the date of this form.
Date
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Month
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Day
Year
Date
According to Medicare rules, we need your permission to contact you to discuss your Medicare plan options. By filling out this form, you are agreeing to a telephone call or an email from a licensed agent to discuss your enrollment and plan options. The person who will be discussing plan options with you is contracted by a Medicare health plan or prescription drug plan that is not the Federal Government and they may be compensated based on your enrollment in a plan. Signing this does NOT affect your current enrollment, nor will it enroll you in a Medicare Advantage Plan, Prescription Drug Plan, or other Medicare plan. Not affiliated with or endorsed by Medicare or any government agency. I/We do not offer every plan available in your area. Any information I/we provide is limited to the plans I/we do offer in your area. Please contact Medicare.gov or 1-800-Medicare to get information on all of your options.
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