Medicare Consultation Intake Form
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit 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.
Do You Currently Have Health Insurance?
*
No
Yes
Current Health Insurance Type
*
Job-based health insurance
Private pay health insurance
Medicare
Name of Current Insurance Company
Date New Medicare Coverage is Needed
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Are You Enrolled in Medicare?
*
No
Yes
Medicare ID Number (if already enrolled in Medicare)
Will Your Spouse Need Medicare Coverage?
No
Yes
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Next
Name of Spouse
First Name
Last Name
Spouse's Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Is Spouse's Residence the Same as Yours? (for plan option purposes)
No
Yes
Spouse Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is Your Spouse Enrolled in Medicare?
*
No
Yes
Spouse's Medicare ID Number
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Next
Do you know what type of Medicare plan you are interested in?
Medicare Advantage (Part C) that includes Part D
Medicare Supplement ("MediGap") + Part D
I do not know yet
Please check off the insurance companies that you may prefer working with:
Aetna
AARP/UnitedHealthcare
Blue Cross Blue Shield
Cigna
Humana
Wellcare
Other
No preference
Signature
Appointment
Continue
Continue
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