ORIGINAL- HIPPA COMPLIANT

FREE QUOTE - HIPPA COMPLIANT

Use the TAB key to move from one field to anther or use your Mouse
Referral Number
Please enter a valid phone number.Format: (000) 000-0000.
Date

MonthDayYear
Today
Referred By
Client Name
Exactly as on the Medicare Card
Address

Residence Address

Mailing Address (If different)

City State

Zip Code
Complete Mailing Address if different
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?
Part A Effective Date

MonthDayYear
Date
Part B Effective Date

MonthDayYear
Date
Do you have a Medicaid number?
If Yes,is it:
Do you Smoke?
Are You disabled?
Form is being completed by:
If Other, do you have Power of Attorney?
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)
If you want us to research drug plans, please provide the following information:
Enter your Pharmacy Name and Location Here
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.
I have Amyotrophic Lateral Sclerosis (ALS or Lou Gehrig's Disease)
| have End Stage Renal Disease (ESRD)
I am enrolled in a Medicare Special Needs (SNP) or Chronic Plan.
I live in a Nursing Home
When did you move there?

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

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

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

MonthDayYear
From Where?
Do you qualify for:
Will you have employer coverage through yourself or you spouse after you turn 65?
If YES does the company pay insurance for more than 20 employees?
$ Monthly Premium
$ Annual Deductible
Do you make more than $106,000 a year if filing single, or more than $212,000 a year if filing jointly with spouse? (If yes, you may be subject to IRMAA - Income Related Monthly Adjustment Amount)
Do you make less than $1,956 a month and have less than $17,600 in assets/resources* if filing single, or make less than $2,643 a month with less than $35,130 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)
Please enter any additional doctors, prescriptions, comments or other information below.
.
.
.
.
Should be Empty:

FREE QUOTE - HIPPA COMPLIANT