New client Medicare Intake Form
Medicare is not one size fits all. Our goal is provide you a personalized experience based on your needs, health, budget, and much more. In order to start the process of helping you, we are requesting the following information:
Section 1 - Base
Full Legal Name
First Name
Last Name
Gender
Male
Female
Date Of Birth
-
Month
-
Day
Year
Date
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you have a separate mailing address?
Yes
No
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Section 2 - Medicare and Medicaid (if any)
Medicare Number (on your red white and blue card)
Hospital Part A Effective Date (on your Medicare Card)
-
Month
-
Day
Year
Date
Medical Part B Effective Date (on your Medicare Card)
-
Month
-
Day
Year
Date
Medicaid Number (only if you have Medicaid)
Do you qualify for Extra Help or Partial Medicaid levels to your knowledge?
Yes
No
I don't know
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Section 3 - Current Rx Details
Configurable list
*
Preferred Pharmacy
Optional Pharmacies if Cost Savings Are Available
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Section 4 - Medical Providers To Ensure Networks Of Coverage
Please list the names for any providers you’ve seen in the last 12 months
Primary Doctor
Configurable list
*
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Section 5 - Personalized Needs
Do you have a retirement health insurance option?
Yes
No
Do you have an current employer coverage option?
Yes
No
Do you qualify for Tricare benefits?
Yes
No
Do you qualify for standard VA benefits?
Yes
No
Would you be interested in discussing assistance programs for limited incomes?
Yes
No
Submit
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