• RIS Medicare Client Intake

    Complete this multi-page intake and review the contact consent notice before submitting.
  • By submitting this form, you agree to be contacted by phone, text, or email by a licensed RIS Medicare agent regarding Medicare Advantage, Medicare Supplement, and Part D plans.

  • Personal Information

  • Contact Information

  • Format: (000) 000-0000.

  • Medicare Information

  • Are you currently enrolled in Medicare?*
  • Do you currently have
  • Do you see any doctors in other states?
  • Do you wear glasses?
  • Do you have hearing aids?
  • Do you have dental coverage?
  • Do you have current dental issues?

  • Health Care

  • Primary Care Physician

  • Format: (000) 000-0000.

  • Specialists

  • Specialists

  • Prescription Drugs

  • Medications
  • Should be Empty: