Medicare Pre-Screen Form

Medicare Pre-Screen Form

Submit this form if you would like us to review the health information your clients provide you. Our team will do the work to try to find solutions. We may reach out with additional questions if clarification is needed.
Agent Name

First NameLast Name
Agent Email
example@example.com
Agent Phone Number

Area CodePhone Number
Client Name

First NameLast Name
DOB or Age:
Gender:
Tobacco Use?
Height & Weight
Zip Code
Does this person live with anyone?
If Yes, will they also be applying?
Does this person have a current Medicare policy (Medicare Supplement or Advantage Plan)?
If yes, what plan and carrier are they currently on?
Ex: American Continental Plan G, Medicare Adv., etc...
What is their current premium?
We will only show options less than their current premium.
Desired Effective Date:

MonthDayYear
Date
What plan are you looking for?
Plan F, Plan G, Plan N, Medicare Advantage, etc...
Health Conditions
Can you perform your Activities of Daily Living without assistance?
Diabetic?
If yes, insulin?
Within the LAST 3 YEARS have you been medically diagnosed, treated or had surgery for:
Within the last 1 year have you been advised by a medical professional to have treatment, further evaluation, diagnostic testing, or any surgery that has not been performed?
If yes, provide details
Within the last 1 year have you received injections in a doctors office?
If yes, provide details
Have you been medically diagnosed, treated, or had surgery for:
Any other health concerns within the last 5 years?

If taking any medications, please list them. If more room is needed, please add to notes below or upload a file.

Rows	Medication	Frequency	Dosage	Reason Taking
#1
#2
#3
#4
#5
#6

Notes:
File Upload

Cancelof
Should be Empty:

Medicare Pre-Screen Form

Health Conditions