Medicare Intake Form

Medicare Intake Form
YesNo
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)
MedicaidTricare for LifeState Retiree InsuranceMedigap
Yes
Your gross monthly income
Your spouse’s gross monthly income
Total Household Income
YesNo
YesNo
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
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