Needs Analysis

Name*

First NameLast Name

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

How did you hear about us?

Referred by:

What is your main concern when it comes to health insurance?

Date of Birth*

Date

Height*

Weight*

Adjusted Gross Household Income*

Any prescription drugs in the past 12 months?*

If yes, please list them below to ensure I find a plan that covers them:

Any diagnosis in the past 5-10 years?*

If yes, please list below:

Are there going to be any other individuals on your plan? (i.e. Spouse and/or kids)

If yes, please provide the following for each individual-Name, Date of Birth, Height, Weight and any Prescriptions.

Appointment Date Request

Date

What time of day works best for a 20-30 minute conversation about your options?

Any DUIs, Felonies, Drug Convictions, Arrests

Current Insurance

Doctor Visits

ER Visit

Hospital Admitted

Last time of meeting a deductible

MD Live

Critical Illness

YesNo

Short Term Disability

YesNo

Life Insurance

YesNo

Dental

YesNoType option 3Type option 4

Vision

YesNo

Likes:

Dislikes:

Budget

Advisor Notes:

Marketplace (ACA) Plans

Limited network
HMO structure
No 24/7 nationwide coverage
Higher deductibles
Out-of-pocket max applies

Private Underwritten Plans

Healthy risk pool
PPO nationwide access
Richer benefits
More affordable when qualified

Limited Benefit Plans

Very inexpensive
No catastrophic coverage
High deductibles ($25k–$50k)
Examples: Southwest, Philadelphia Life, UHC Golden Rule

Faith-Based Plans

Not insurance
Not governed by Dept. of Insurance
Not required to pay claims

***Medi-Share is a nonprofit health care sharing ministry of Christian Care Ministry, Inc (“CCM”). Medi-Share members voluntarily share each other’s medical expenses in accordance with guidelines adopted by the members and administered by CCM. Medi-Share is not insurance and is not regulated as insurance. Neither CCM nor any Medi-Share member assume any legal obligation to share in the payment of any medical expense incurred by another Medi-Share member. Medi-Share members are exempt from the individual mandate in the Patient Protection and Affordable Care Act. See 26 U.S.C §5000 A(d)(2)(B). Certain states expressly exempt from insurance regulation healthcare sharing ministries that, among other things, post a specific notice. Although Medi-Share does not rely on such express exemptions, Medi-Share has elected to publish theses notices. You can review the disclosure required for the state in which you reside: KY, MD, PA, WI - All Other States.

Marketplace limitations discussedPrivate underwritten plans explainedLimited benefit plans reviewedFaith-based plans ruled out

Steve Rybacki Appointment Form