ORIGINAL- HIPPA COMPLIANT

FREE QUOTE - HIPPA COMPLIANT

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Insurance and Other Red Tape - Bonnie Dobbs Agency
Date

MonthDayYear
Today
Referred By
Referral Number
Please enter a valid phone number.Format: (000) 000-0000.
Client Name*
Exactly as on the Medicare Card
Address

Residence Address

Mailing Address (If different)

City State

Zip Code
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
County*
Other Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Birthdate*

MonthDayYear
Date
Do you have a Medicare number?

YesNo
Part A Effective Date

MonthDayYear
Date
Part B Effective Date

MonthDayYear
Date
Do you have a Medicaid number?

YesNo
If Yes,is it:

FullPartial
Do you Smoke?

YesNo
Are You disabled?

YesNo
Form is being completed by:

ClientOther
If Other, do you have Power of Attorney?

YesNo
If Other, please provide Full Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Other's Relationship
Email Address
example@example.com
Current Insurance Plan (s) (if any):
Primary Care Physicians/Specialist Currently seeing: (first & last name, type of doctor, city and phone number)
Primary Care Physicians/Specialist Currently seeing: (first & last name, type of doctor, city and phone number)
Primary Care Physicians/Specialist Currently seeing: (first & last name, type of doctor, city and phone number)
Primary Care Physicians/Specialist Currently seeing: (first & last name, type of doctor, city and phone number)
Put the Pharmacy Name Here
If you want us to research drug plans, please provide the following information: PHARMACY:
Enter your Pharmacy Name Here
PHARMACY NAME

Do NOT use the ENTER key with the Prescriptions Information
Prescription Drugs
Dosage(Mg)
Frequency
Prescription Drugs
Dosage(Mg)
Frequency
Prescription Drugs
Dosage(Mg)
Frequency
Prescription Drugs
Dosage(Mg)
Frequency
Prescription Drugs
Dosage(Mg)
Frequency
Prescription Drugs
Dosage(Mg)
Frequency
Prescription Drugs
Dosage(Mg)
Frequency
Prescription Drugs
Dosage(Mg)
Frequency
Prescription Drugs
Dosage(Mg)
Frequency
Prescription Drugs
Dosage(Mg)
Frequency
Prescription Drugs
Dosage(Mg)
Frequency
Prescription Drugs
Dosage(Mg)
Frequency
PLEASE CHECK ALL THAT APPLY
I have Federal Employee Health Benefits (FEHB) or State or local retiree health benefits.

Yes
I have Amyotrophic Lateral Sclerosis (ALS or Lou Gehrig's Disease)

Yes
| have End Stage Renal Disease (ESRD)

Yes
I am enrolled in a Medicare Special Needs (SNP) or Chronic Plan.

Yes
I live in a Nursing Home

Yes
When did you move there?

MonthDayYear
I live outside the U.S. and plan to move back

Yes
When

MonthDayYear
I am planning to move outside the U.S.

Yes
When

MonthDayYear
I recently moved out of my state, county or zip code

Yes
When

MonthDayYear
From Where?
Do you qualify for:

VATriCareChampVA
Will you have employer coverage through yourself or you spouse after you turn 65?*

YesNoSelfSpouse
If YES does the company pay insurance for more than 20 employees?

YesNo
$ Monthly Premium
$ Annual Deductible
Do you make more than $109,000 a year if filing single, or more than $218,000 a year if filing jointly with spouse? (If yes, you may be subject to IRMAA - Income Related Monthly Adjustment Amount)

NoYes
Do you make less than $1,956 a month and have less than $23,475 in assets/resources* if filing single, or make less than $2,643 a month with less than $31,725 in assets/resources if filing jointly? *Does not include your home, vehicles, personal possessions, life insurance or burial plots/contracts...(If yes, you may qualify for Extra Help or LIS - Low Income Subsidy)

NoYes
Please enter any additional doctors, prescriptions, comments or other information below.
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Should be Empty:

FREE QUOTE - HIPPA COMPLIANT

PHARMACY NAME