Client Information Form

Client Information Form

Medicare
Legal Name*

First NameMiddle NameLast Name
Birthday*

MonthDayYear
Gender*
Primary Phone Number*
Please enter a valid phone number.
Is this a cell phone or land line?*
Mobile
Please enter a valid phone number.
Email Address *
example@example.com
It's okay to communicate with me via:

EmailText
Are you a U.S. citizen?*

YESNO
Are you legally present in the US?*

YESNO
Home Address *

Street Address

Street Address Line 2

CityState

Zip CodeCountry
County*

Additional Health Information
Are you currently receiving Medicaid benefits?*

YESNO
Medicaid ID #*
Do you receive any financial assistance? (LIS/Extra Help)*

YESNO
Do you use tobacco?*

YESNO
Medicare ID #
Part A Effective Date

MonthDayYear
Date
Part B Effective Date

MonthDayYear
Date
Do you have any chronic conditions? (Heart Disease, Diabetes, Asthma, etc...)

YesNo
If you'd like to describe any details about your chronic conditions, it may be helpful in recommending plans

Physician and Medication Information
Physician Information
Do you take any prescribed medications?*

YESNO
Prescribed Medications*
Your Preferred Pharmacy

Additional Comments
Is there anything else you'd like us to know?*
If there's anything else you'd like us to know, please leave it below
Confidentiality Notice
All information contained in this questionnaire is strictly confidential and used solely for seeking benefits to match the best plan for your needs.

*Consulting Agreement fee may be required.

You can reach us directly anytime at 706-257-5073 or info@michellecrawfordbenefits.com
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