Medicare Intake Form
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Personal Email
*
example@example.com
Preferred Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Are You Enrolled in Medicare?
*
No
Yes
Medicare ID Number (if already enrolled in Medicare)
*
Medicare Part A Effective Date (check your Medicare card)
*
-
Month
-
Day
Year
Date
Medicare Part B Effective Date (if enrolled - check your Medicare card)
-
Month
-
Day
Year
Date
Are you currently enrolled in a Medicare Supplement Plan?
Yes
No
Medicare Supplement Plan Name
*
Medicare Supplement Plan Type
*
Are you currently enrolled in a Medicare Advantage Plan?
Yes
No
Medicare Advantage Plan Name
*
Current Medical Plan (if any)
Current Prescription Drug Plan (if any)
Back
Next
Do You Take Prescription Medications Currently?
*
No
Yes
Tell Us About Your Current Prescriptions
Rows
Prescription Name (as shown on bottle)
Dosage(cap/tab)
Frequency
Refill Frequency (e.g. 30 day)
Brand or Generic
Rx 1
Rx 2
Rx 3
Rx 4
Rx 5
Do you need additional space to add more medications?
*
No
Yes
Additional space for Current Prescriptions
Rows
Prescription Name
Dosage(cap/tab)
Frequency
Refill Frequency
Brand or Generic
Rx 6
Rx 7
Rx 8
Rx 9
Rx 10
Preferred Retail Pharmacy Name
*
Preferred Retail Pharmacy Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Back
Next
Please list all Doctors. (including but not limited to PCP, Specialists, Dentist, etc.)
Rows
First Name
Last Name
Specialty
City/Town/Zip
Dr. 1
Dr. 2
Dr. 3
Dr. 4
Dr. 5
Do you need additional space to add more doctors?
*
No
Yes
Additional space for Doctors. (including but not limited to PCP, Specialists, Dentist, etc.)
Rows
First Name
Last Name
Specialty
City/Town/Zip
Doctor 6
Doctor 7
Doctor 8
Doctor 9
Doctor 10
Notes or Important Additional Information
Submit
Should be Empty: