Medicare
Client Intake Form
STATUS:
New
Processing
Complete
Today's Date:
-
Month
-
Day
Year
Are you a new client?
*
Yes
No
Source/Referred By:
Medicare Plan Effective Date:
-
Month
-
Day
Year
Date
Election Period:
Current Plan:
New Plan:
Personal Information
Name:
*
First Name
Middle Name
Last Name
Address:
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
*
County
Is this also your mailing address?
Yes
No
Language:
English
Spanish
Phone:
*
Email:
Date of Birth:
*
-
Month
-
Day
Year
Date
Social Security #:
Other Contact Name:
Phone:
Relationship:
Medical Information
Medicare Number:
Part A Date:
-
Month
-
Day
Year
Date
Part B Date:
-
Month
-
Day
Year
Date
Do you have Medicaid?
Yes
No
I do not qualify
If yes, do you have:
QMB
SLMB
QL1
I don't know
Medicaid Number:
If no:
Help me apply
Not interested in applying
Are you in the Low Income Subsidy (LIS) Extra Help program?
Yes
Don't qualify
No
Help me apply
If so, what percentage?
Any chronic conditions?
Are you a veteran?
Yes
No
Are you in a nursing home?
Yes
No
Income Information
Your monthly income:
Your spouse's monthly income:
Your total monthly income:
Has your income changed this year?
Yes
No
Do you or your spouse work?
Yes
No
Providers/Doctors
Primary Care Physician:
Are you currently a patient?
Yes
No
Address:
Phone:
Specialist:
Specialty:
Address:
Phone:
Specialist:
Specialty:
Address:
Phone:
Specialist:
Specialty:
Address:
Phone:
Vision Provider:
Address:
Phone:
Dentist:
Address:
Phone:
Pharmacy:
Dialysis Center:
Order Diabetic Supplies:
Yes
No
Date:
-
Month
-
Day
Year
Date
Please list your prescriptions (name, dosage, strength):
Provide any additional details below.
Submit
Should be Empty: