Medicare Supplement Health Questions

In North Carolina, you may apply for a new Medicare Supplement (MediGap) plan year-round. Unlike during the Annual or Open Enrollment periods, the insurance companies will ask health questions.

This form will give us a good starting point to choose the company and plan type for acceptance with an effective plan and lower premiums.

Please read through the following health questions and answer "Yes" or "No" at the end. You will be given the chance to give details if you answer "Yes" to any of the questions.

1) Have you been hospitalized or in the emergency room two or more times within the past 12 months?

2) Are you currently taking, or within the last two years, have taken medication or been advised to take medication for or received medical advice, treatment or been advised that you need treatment or surgery for any of the following:

2a) Heart, Coronary, or Cartoid Artery Disease, Peripheral Vascular Disease, Congestive Heart Failure or any other type of Heart Failure, Stroke, Transient Ischemic Attacks (TIA), or Heart Rythm Disorders?

2b) Emphysema, Chronic Obstructive Pulmonary Disease (COPD), or other Chronic Pulmonary disorders?

2c) Parkinson's Disease, Multiple or Lateral Sclerosis, Huntington's Disease, Muscular Dystrophy, Systemic Lupus, Hepatitis (excluding A or E), Lou Gehrig's Disease?

2d) Inflammatory Bowel Disease, Crohn's Disease, Ulcerative Colitis, or Barrett's Esophagus?

2e) Alzheimer's Disease, senile dementia, brain seizures, epilepsy, senility disorder, schizophrenia, major depressive disorders, other mental or nervous disorders, alcoholism, or drug abuse?

2f) Acquired Immunodeficiency Syndrome (AIDS), AIDS Related Complex (ARC), Human Immunodeficiency Virus (HIV) infection or blood disorder?

2g) Kidney disease requiring dialysis or kidney failure? Liver disease or disorder, cirrhosis?

2h) Internal cancer, leukemia or melanoma?

2i) Rheumatoid arthritis, Paget's Disease, Osteoporosis, degenerative bone or joint disorder, degenerative disk disease, crippling arthritis, vertebral or hip fractures/dislocations, spinal cord disorders/injuries, or chronic pain?

2j) Organ, bone marrow or stem cell transplant or awaiting transplant (exluding corneas)?

3 Diabetes? Have you been diagnosed with or treated for diabetes:

3a) Requiring more than 50 units of infusion daily?

3b) Requiring three (3) or more medications (oral or injections) to control blood sugar?

3c) Or only if you have Neuropathy, Retinopathy, any kidney problems, proteinuria, or any circulation problems?

Type a question

If you answered "Yes" to any of the questions above, please note any details.

Please list any prescription drugs you're currently taking or have taken in the past 2 years.

Rows	Name	Dosage Amoount	Frequency Taken	Reason for taking
Medication 1
Medication 2
Medication 3
Medication 4
Medication 5
Medication 6

Name of Primary Care Doctor

First NameLast Name

Name of Practice

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of last visit to your Primary Care Doctor

Date

Reason for visit

Name(s) of any Specialist you see routinely

Rows	Name	Reason for visit
Specialist 1
Specialist 2
Specialist 3
Specialist 4

Any tobacco usage?

Height

Weight

Would you consider a Medicare Advantage Plan with no health questions and no pre-existing exclusions? Five Star and Chronic Disease - Heart & Diabetes plans are available year-round.

Your Name

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Notice of Privacy

The information provided herein is private and confidential, and is protected under the Health Insurance Portability and Accountability Act (HIPAA). Unauthorized use, disclosure, or distribution of this information is strictly prohibited and may result in legal consequences.

We do not offer every plan available in your area. Currently we represent at least 8 organizations which offer at least 57 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.

Trout Insurance is a full line insurance agency based in WNC. We serve clients in North and South Carolina as well as national companies. Trout Insurance offers life, health, disability, Medicare supplement, Medicare Health Plans, Medicare Prescription Plans, Long term care insurance, Home and Auto insurance for individuals.