Medicare Beneficiary Intake Form
Please fill out this form to help us better understand your needs in choosing a plan.
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Have you recently moved to a new county of residence?
Yes
No
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
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Authorized Representative(s)
Please list anyone you would like us to have on record who is allowed to make decisions on your behalf, if necessary.
Authorized Representative(s)
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Medicare & Medicaid
Medicare Number
*
If you do not have a Medicare number yet, type "None"
Part A Effective Date
*
-
Month
-
Day
Year
Choose today's date if you have not received your Medicare Card yet
Part B Effective Date
*
-
Month
-
Day
Year
Choose today's date if you have not yet received your Medicare card
Medicaid Member ID (Skip if not applicable)
This is a 9-digit number located on the front of your Medicaid card
What level of Medicaid do you currently have?
Please Select
DLMB
SLMB
QI
QMB
QMB+
FIDE
HIDE
This information is typically located on the lower right corner of your HHS Medicaid Card
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Employer-Based Coverage
Are you currently enrolled in employer-based healthcare?
*
Yes
No
If yes, what is the ending date of your employer-based coverage?
-
Month
-
Day
Year
Do you have any pending surgeries, procedures or imaging scheduled?
*
Yes
No
When is the date of your procedure?
-
Month
-
Day
Year
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Prescriptions
Please list all of your prescriptions below. Exclude vitamins/OTC like Tylenol,etc.
*
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Doctors
Please list all of your doctors below. To add more doctors, simply hit the "+ Add Doctor" as many as times as you need
*
Submit
Should be Empty: