LATZ Financial Solutions — Medicare Client Intake

LATZ Financial Solutions — Medicare Client Intake

Share your current coverage, doctors, prescriptions, and preferences to help prepare for your Medicare appointment (not an enrollment form).
Contact
Beneficiary Full Name

First NameMiddle NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Street Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
City
State
ZIP Code
County
Preferred Contact Method
Best Contact Time

Hour Minutes

AM/PM Option
Are You Completing This Form for the Beneficiary?
Representative Name

First NameMiddle NameLast Name
Relationship to Beneficiary
Representative Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Current Coverage
Please have your Medicare card available for your appointment. Do not enter Medicare or Social Security numbers here.
Do you currently have Medicare?
Part A effective date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Part B effective date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Current carrier
Current plan name
Current coverage types

Other
Do you have Medicaid?
Do you receive Extra Help?
Upcoming coverage changes
Providers
Do you have a primary doctor?
Primary doctor name

First NameLast Name
Primary practice or location
Primary doctor city
Do you have specialists?
Specialists and preferred providers
Prescriptions
Are you currently taking any prescription medications?
Medication details
Pharmacy name
Pharmacy location

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Pharmacy preference
Additional prescription notes
Preferences
What would you like help reviewing?

Other
Biggest concerns or questions for the appointment
Acknowledgment
I confirm that the information I provided is accurate to the best of my knowledge.
Date completed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signer name (if signing as a representative)

First NameMiddle NameLast Name
Should be Empty:

LATZ Financial Solutions — Medicare Client Intake

Contact

Current Coverage

Providers

Prescriptions

Preferences

Acknowledgment