Medicare Intake Sheet
Personal Information
Full Legal Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Trusted Contact Name
*
First Name
Last Name
Trusted Contact Phone Number
*
Please enter a valid phone number.
Marital Status
*
Unmarried
Married
Divorced
Widowed
Spouse Name
*
First Name
Last Name
Spouse Date of Birth
*
-
Month
-
Day
Year
Date
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Current Medicare Coverage
Medicare number
*
Part A Effective Date
*
-
Month
-
Day
Year
Date
Part B Effective Date
*
-
Month
-
Day
Year
Date
Do you have additional private coverage?
*
Yes
No
What private plan do you currently have?
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Program Enrollment
Medicaid?
*
Yes
No
Qualified Medicare Beneficiary (QMB)?
*
Yes
No
Low Income Subsidy (LIS)?
*
Yes
No
Are you considered disabled?
*
Yes
No
Are you a veteran?
*
Yes
No
Do you receive prescriptions or medical care from the VA?
*
Yes
No
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Type a question
Doctor
Specialty
Doctor 1
Doctor 2
Doctor 3
Doctor 4
Type a question
Drug Name
Dosage
Number of Pills Per Day
Prescription 1
Prescription 2
Prescription 3
Prescription 4
Prescription 5
Prescription 6
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Any additional notes?
Submit
Should be Empty: