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.
Email
*
example@example.com
Back
Next
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)
Back
Next
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
Back
Next
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
Back
Next
Prescriptions
Please list all of your prescriptions below. Exclude vitamins/OTC like Tylenol,etc.
*
Back
Next
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: