Lourie - Medicare Questionnaire

Medicare Questionnaire
Personal Information
Name (Required)

First NameLast Name
Birth Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number

Area CodePhone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState

Zip Code
County
Disclaimer:

A sales agent may mail, call or e-mail as a result of completing the information to discuss Medicare Advantage, Prescription Drug Plans or Medicare Supplement Insurance.
Medicare Information

Found on red, white, and blue card
Full Name (on Medicare card)

First NameLast Name
Do you have Original Medicare Part A?
When did/does your Part A start?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Do you have Original Medicare Part B?
When did/does your Part B start?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Medicare Number:
Additional Medicare Coverage
Do you have a Medicare Supplement (Medigap) or Medicare Advantage Plan (Part C)? (Provide Plan and Company Name)
Do you have a Prescription Drug (Part D) plan, usually paired with a Medicare Supplement plan? (Please provide plan and company name)
Other Insurance Coverage

What prescriptions (not over the counter) do you take regularly (include dosage and frequency taken)?

Please select the following items that apply to you:

Rows	Yes	No
Group health plan
Medicaid
Extra Help from Social Security
Supplement Security Income
Social Security Income

Medicaid Number:
What is your primary pharmacy and address?
Do you prefer or would you consider using a mail order pharmacy for your prescription?

Please enter any doctors or dentists you see on a regular basis:

What doctors do you see on a regular basis?
Concerns you want to address regarding your current plan coverage.
Disclaimer: A sales agent may mail, call, or e-mail as a result of completing the information to discuss Medicare Advantage, Prescription Drug Plans, or Medicare Supplement Insurance. All information provided is collected, used, and stored in accordance with all HIPAA guidelines. Additionally, by submitting this form you are giving Lourie Life and Health consent to share your information with one of our affiliated agent partners.
Should be Empty:

Personal Information