Medicare Pre-Screen
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
Height & Weight
*
Tobacco Use?
*
Yes
No
Zip Code
*
Does this person live with anyone?
Yes
No
If Yes, will they also be applying?
Yes
No
Does the client 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
Health Conditions
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
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 been medically diagnosed, treated, or had surgery for:
Heart Attack
Had a seizure
Any other health concerns within the last 5 years?
If taking any medications please list them, attach an additional page if needed.
Medication
Frequency
Dosage
Reason Taking
Notes:
Submit
Should be Empty: