BASIC INFORMATION
Client Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
E-mail
example@example.com
Date of Birth
-
Month
-
Day
Year
Zip Code
Street Address
Street Address Line 2
City
State / Province
Questions
Back
Next
CURRENT COVERAGE
What is your current Medicare or insurance situation?
I am not yet enrolled in Medicare
I have Original Medicare only (Parts A and B)
I have Medicare Advantage (Part C)
I have a Medicare Supplement (Medigap) plan
I have VA benefits
I have employer or retiree coverage
Other
If you are currently enrolled in a Medicare Advantage or Part D plan, have you received an Annual Notice of Change letter that raised any concerns about your coverage?
Yes, I have concerns I would like to discuss
No, I have not received one or have no concerns
I am not sure what this is
Back
Next
HEALTHCARE PROVIDERS AND MEDICATIONS
Do you have a primary care physician you want to keep?
Yes
No
I am currently looking for a new primary care physician
Do you have specialists, hospitals, or health systems that are important to you and that you want to make sure remain accessible under your plan?
Yes
No
Not sure
Do you currently take prescription medications on a regular basis?
Yes
No
Back
Next
COVERAGE PREFERENCES AND FINANCIAL CONSIDERATIONS
When it comes to how you pay for healthcare, which approach best describes your preference?
I prefer a fixed cost model with higher monthly premiums for more predictable expenses
I prefer lower monthly premiums and am comfortable with higher cost-sharing when I use care
I am not sure and would like help understanding the difference
It depends and I would like to discuss
Is the annual out-of-pocket maximum a concern for you in the event of a significant health event?
Yes, this is a priority for me
Not a primary concern right now
I am not familiar with how out-of-pocket maximums work and would like it explained
Are there any financial considerations or budget parameters we should be aware of when reviewing your options?
Back
Next
LIFESTYLE
What are your lifestyle goals for the next 12 months? Please select all that apply.
Domestic travel
International travel
Participating in physical activities such as hiking, yoga, cycling, or fitness programs
Staying primarily local
Exploring alternative or integrative healthcare
Managing one or more ongoing health conditions
Caregiver responsibilities for a family member
Other
Is there anything else you would like us to know before our consultation?
Back
Next
Submit
Should be Empty: