KFWE Medicare Information & Needs Intake
Share what Medicare questions you have—this is a preliminary inquiry, not a Medicare enrollment application.
Contact Information
First Name
*
Last Name
*
Email
*
example@example.com
Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Contact Method
*
Phone
Email
Text
Preferred Contact Time
*
Morning
Afternoon
Evening
Medicare Timing
Which best describes you?
*
I’m turning 65 soon
I’m already enrolled in Medicare
I’m helping a family member with Medicare
I’m losing employer/union coverage
I’m not sure when I need to enroll
Other
What state do you live in?
*
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Other
What county do you live in?
*
What They Want Help With
What would you like help with?
*
Understanding Medicare basics
Medicare Advantage (Part C)
Prescription drug coverage (Part D)
Medicare Supplement (Medigap)
Comparing Original Medicare and Medicare Advantage
Understanding enrollment timing
Understanding costs/premiums
Checking whether my doctors/medications may be considered when comparing options
I’m not sure — I just want someone to explain my options
Other
If you selected Other, please describe
How familiar are you with Medicare today?
Just starting to learn
Somewhat familiar
Very familiar
Prefer not to say
Do you want help comparing coverage options?
Yes
No
Not sure
Would you like help understanding enrollment timing?
Yes
No
Not sure
Would you like help understanding monthly costs?
Yes
No
Not sure
Would you like help checking whether your doctors may be considered in a comparison?
Yes
No
Not sure
Would you like help checking whether your medications may be considered in a comparison?
Yes
No
Not sure
Would you like help with Original Medicare, Medicare Advantage, or both?
Original Medicare
Medicare Advantage
Both
Not sure
Tell us anything else about what you need help with
Current Coverage
What coverage do you have now?
*
Original Medicare
Medicare Advantage
Employer/Union coverage
Medicaid
VA/TRICARE
Not sure
Not yet enrolled
Other
Are you currently enrolled in Medicare Part A?
*
Yes
No
Not sure
Are you currently enrolled in Medicare Part B?
*
Yes
No
Not sure
General Needs
What is most important to you when learning about your Medicare options?
Keeping current doctors
Prescription coverage
Monthly costs
Predictable costs
Travel/flexibility
Extra benefits
Understanding how coverage works
Not sure
Is there anything specific you would like us to explain?
Contact Permission / Acknowledgment
Notice
Consent and Acknowledgment
*
I understand that I am requesting information about Medicare and authorize KF Wealth & Education Group to contact me regarding the Medicare information I requested. I understand this does not enroll me in a Medicare plan.
I understand that a separate Scope of Appointment or other required documentation may be needed before a one-on-one Medicare marketing appointment or plan-specific discussion.
Submit
Should be Empty: