Medicare Intake Form

Medicare Intake Form
Appointment Date

MonthDayYear
Date
Appointment Time
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
Alternate Telephone
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:

MedicaidTricare for LifeState Retiree InsuranceMedigap
Do you use Baptist Hospitals or physicians?

Yes
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)?

YesNo
Do you receive assistance for extra help (LIS)?

YesNo
Income Limits For MSP/LIS

QMB (Single $1325/Married $1783) AMASLMB (Single $1585/Married $2135) AMAQI-1 (Single $1781/Married $2400) AMALIS/EXTRA HELP (Single $1986.25/Married $2673.74) SSA
Which of the following apply to you?

The client does not take any prescription medications.The client did not have his/her medication list at the time of the intake; will provide list at a later time.Do NOT include Over the Counter Medications.

Medications