Client Needs Assessment

Client Needs Assessment
Name

First NameLast Name
Phone
Address
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Text? Y/N
Email
example@example.com
Contact method preferred
Are you a current Medicare beneficiary or new to Medicare?

CurrentNew
Medicare Number
Effective Date Part A

MonthDayYear
Date
Effective Date Part B

MonthDayYear
Date
Medicaid
Are you a veteran?

YesNo
If yes, which branch?
Why are you wanting to make changes now?

Aging inAnnual renewalMovingNew diagnosisChange in financesExploring my optionsOther
Power of Attorney
Do you have a Healthcare POA or someone who helps with medical decisions?

YesNo
Name
Relationship
Phone Number
Please enter a valid phone number.
Email
example@example.com
Current Coverage
Select any that apply:

ACACobraVATricareMedicaidMed-SuppOriginal MedicareCompany Provided Plan (currently working)Company Provided Retirement PlanMedicare Advantage PlanMedicare Advantage Special Needs PlanDentalVisionHearingIndemnityOther
Carrier
Plan
Premium
Carrier
Plan
Premium
Would you like information about programs that may help cover costs?

YesNo
How do your monthly premiums fit into your budget?
What is prompting you to review your coverage today?
If you could change anything about your healthcare coverage, what would it be?

Premium CostCopay/Coinsurance costProvidersBenefitsPlan StructureOther
What parts of your current coverage do you like?
Do you currently have a Primary Care Physician (PCP)?

YesNo
PCP

NameLocation

Providers

Would you consider changing your Primary Care Physician if it meant getting into a plan that better suits your needs?

YesNo

Prescriptions

Would you like information about any plans in the area that may offer special coverage for beneficiaries with certain medical conditions, including diabetes, heart conditions, or Chronic Obstructive Pulmonary Disease (COPD)

YesNo
What do you consider to be the most important aspects of medical coverage? (Select any that apply)

ProvidersPrescription CostPremium CostCopay CostPlan extras like Gym Membership, Transportation, Dental, Vision, and/or Over the Counter benefits
Are you concerned about paying for things like copays, deductibles, and coinsurance?

YesNo
Signature

Powered by Jotform SignClear
This guide is provided by Belle Vida Insurance for use during the sales process by a licensed insurance agent. Information contained in this questionnaire will be protected under the federal Protected Health Information guidelines. The information contained in this questionnaire will not be used for any other purpose or shared with any other entities.
Should be Empty:

Current Coverage