Medicare Intake Form
Full Name
*
First Name
Last Name
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County
*
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Medicare Part A Effective Date (MM-01-YYYY)
*
Medicare Part B Effective Date (MM-01-YYYY)
*
Medicare ID Number
*
Medi-Cal or Medicaid Number
*
Receive any of the following?
*
VA Benefits
Tricare For Life
Teachers' Retirement
Firefighters' Retirement
Post Office Retirement
Other
Social Security Number
Current Insurance Company
Current Prescription Drug Plan
Primary Care Provider's Name
First Name
Last Name
Primary Care Provider's Clinic Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Care Provider Phone
Please enter a valid phone number.
Format: (000) 000-0000.
List all Specialists' Full Name and Specialty (e.g. Dr. Maria Smith, Opthalmologist)
Preferred Pharmacy
Preferred Pharmacy's Location
30 day or 90 day supply of medication?
30 day
90 day
Prescription Drug List (Drug Name - Dosage - Frequency; e.g. Setraline - 25 mg - 1 x a day)
Any medical diagnosis; i.e. Diabetes, ESRD, Cardiovascular, Pulmonary
I am leaning towards...
*
Straight Medicare Only and just need a Prescription Drug Plan
Medicare Supplement with Prescription Drug Plan
Medicare Advantage or Part C
Not sure; I'd like us to discuss my options
Bundle, Signature, and Date
I am interested in these products
*
Dental
Vision
Life Insurance
Home Insurance
Travel Medical Insurance
Commercial Insurnance
None
Signature
*
Date
*
-
Month
-
Day
Year
Date
Continue
Continue
Should be Empty: