Medicare Pre-Screen Form
Submit this form if you have someone with a concerning medical history. Our team will do the work to try and find solutions. We may reach out with additional questions if clarification is needed.
Agent Name
*
First Name
Last Name
Agent Email
*
example@example.com
Agent Phone Number
*
-
Area Code
Phone Number
Client Name
First Name
Last Name
DOB or Age:
*
Gender:
*
Male
Female
Tobacco Use?
*
Yes
No
Height & Weight
Zip Code
*
Does this person live with anyone?
Yes
No
If Yes, will they also be applying?
Yes
No
Does this person have a current Medicare policy (Medicare Supplement or Advantage Plan)?
Yes
No
If yes, what type of Plan, Carrier, and Premium
Plan F, Plan G, Medicare Advantage, etc...
Desired Effective Date:
-
Month
-
Day
Year
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?
Yes
No
Diabetic?
Yes
No
If yes, insulin?
Yes, add units in Medication List
No
Within the LAST 3 YEARS have you been medically diagnosed, treated or had surgery for:
Atrial Fibrillation
Internal Cancer
Melanoma
Stroke
Any lung or respiratory disorder requiring the use of a nebulizer or oxygen
Arthritis that restricts mobility activities of daily living
Peripheral vascular disease
Heart Attack
Seizures
None
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?
Yes
No
If yes, provide details
Within the last 1 year have you received injections in a doctors office?
Yes
No
If yes, provide details
Have you been medically diagnosed, treated, or had surgery for:
Heart Attack
Seizure
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
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