Medicare Intake Form

Medicare Intake Form
Would you like to be called for an appointment?
Today’s Date

MonthDayYear
Date
Form is ONLY for individuals who are current Medicare recipients or within 3 months. Updated 10/09/2024

ALL SECTIONS OF THIS FORM MUST BE COMPLETED.
NAME
MEDICARE CLAIM NUMBER
Telephone
Format: (000) 000-0000.
Alternate Telephone
Format: (000) 000-0000.
Email
example@example.com
Spouse's Name
Spouse's Date of Birth

MonthDayYear
Date
ENTITLED TO
HOSPITAL (PART A):

MonthDayYear
Effective Date
MEDICAL (PART B)

MonthDayYear
Effective Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
COUNTY
RACE
Date of Birth

MonthDayYear
Date
PRIMARY PHYSICIAN
PREFERRED PHARMACY
PART D PROVIDER (PDP)
HEALTH INSURANCE PROVIDER:
Do you use Baptist Hospitals or physicians?
Your gross monthly income
Your spouse’s gross monthly income
Total Household Income
Does the state of ALABAMA pay your Medicare Part B Premium (MSP)?
Do you receive assistance for extra help (LIS)?
Income Limits For MSP/LIS
Which of the following apply to you?

Medications