MEDICARE INTAKE-FORM

NAME: (EXACTLY AS IT APPEARS ON YOUR MEDICARE CARD, SAMPLE PHOTO ABOVE)*

FIRST NAMELAST NAME

MEDICARE #: (SAMPLE PHOTO ABOVE)*

HOSPITAL [PART A] Effective Date: (SAMPLE PHOTO ABOVE)*

MEDICAL [PART B] Effective Date: (SAMPLE PHOTO ABOVE)*

DO YOU HAVE MEDICAID?

YESNO

STATE MEDICAID CARD NUMBER:

DATE OF BIRTH:*

HOME ADDRESS:*

CITYSTATE

ZIP CODE

COUNTY:*

COUNTY NOT COUNTRY

EMAIL ADDRESS:

CONTACT #:*

DO YOU AGREE TO RECEIVE OCCASIONAL TEXT FROM ME?*

YESNO

PREFERRED METHOD OF CONTACT:*

PHONE CALLTEXT MESSAGEEMAIL

EMERGENCY CONTACT:

FIRST NAMELAST NAME

CONTACT #:

RELATIONSHIP:

DO YOU CURENTLY HAVE SOMEONE THAT ASSISTS YOU WITH YOUR HEALTH PLAN QUESTIONS, AGENT/POWER OF ATTORNEY?

YESNO

WHICH HEALTH PLAN DO YOU CURRENTLY HAVE RIGHT NOW?*

NAME OF CURRENT PLAN:

PLEASE LIST YOUR PCP OR SPECIALIST + ADDRESS: (Dr. Jane Doe, Philadelphia, PA)*

PLEASE LIST YOUR PRESCRIPTION DRUGS TO ENSURE THEY ARE COVERED BY YOUR PLAN: Example: Drug Name: Metformin | Dosage: 10 mg | Quantity Per Month : 30)*

PREFERRED PHARMACY AND ADDRESS: (CVS - Ridge Ave, Philadelphia, PA 19128)*

WHICH BENEFIT WOULD BE PERFECT FOR YOU?

IS THERE ANYTHING ELSE YOU WANT ME TO KNOW BEFORE WE TALK?

PLEASE TAKE A PICTURE OF YOUR MEDICARE CARD AND UPLOAD IT HERE:

This is a solicitation for insurance. By completing this form, you authorize Ray & Fate Indiano, owners and principal agent at Life We Care LLC, to contact you now or during the next open enrollment period when new benefit information is available.

Ray & Fate are licensed insurance brokers - appointed, certified, and trained to represent multiple insurance plan options, which include, but are not limited to, Medicare supplements, Medicare Advantage plans, Life, Health, and stand-alone prescription drug plans. We are not associated with the Center for Medicare and Medicaid Services or any other state or federal agency.

We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. If you would like to find more information about the program, please visit the Official U.S. Government website for Medicare, [www.medicare.gov]; or call 1-800-MEDICARE, thats (1-800-633-4227) TTY users can call: 1-877-486-2048, you can talk/chat live with a real person, 24 hours a day, 7 days a week (except some federal holidays); or you can contact your local State Health Insurance Assistance Program (SHIP) to get information on all of your options.

MEDICARE CHECKLIST

MEDICARE CHECKLIST