New to Medicare Fact Finder
This short form helps us understand your current coverage, priorities, concerns, doctors, prescriptions, and goals as you transition into Medicare. This form is encrypted and secure.
Basic Information
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Medicare Effective Date / Turning 65 Date
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Month
-
Day
Year
Date Picker Icon
MBI Number
*
If Not Enrolled in Medicare A/B type NA
Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
ZIP Code / County
*
Preferred Contact Method
*
Phone
Email
Text
Video call
In-person
Current Health Coverage
Current health insurance provider
*
Type NA if no Coverage or Unknown
Current plan type
*
Employer plan
Spouse’s employer plan
Individual / Marketplace plan
COBRA
Retiree plan
VA / TRICARE
Medicaid
Other
Plan name (if known)
Plan to keep any current coverage after Medicare begins
*
Yes
No
Unsure
Current Plan Experience
What do you like most about your current plan?
*
What do you dislike about your current plan?
*
Have you had any recent frustrations with your current coverage?
*
Yes
No
If yes, please briefly explain the frustrations.
Medicare Goals and Priorities
Top priority or goal as you move into Medicare coverage
*
What are your top 3 priorities?
*
Lowest monthly premium
Predictable out-of-pocket costs
Keeping my current doctors
Strong prescription drug coverage
Freedom to see specialists
Dental, vision, and hearing benefits
Travel flexibility
Simple plan with fewer surprises
Long-term rate stability
Other
Any non-negotiables to protect
*
Doctors, Hospitals, and Prescriptions
Primary Care Doctor
*
Type NA if None
Specialists to Keep
*
List Dr Name(s) and Specialty
Preferred Hospital or Medical System
*
Willing to Change Doctors if Needed
*
Yes
No
Only if necessary
Unsure
Do You Take Prescription Medications?
*
Yes
No
Medication List
*
I will upload it
I will email it
I will provide it during our appointment
I do not take prescriptions
Preferred Pharmacy
*
Budget and Coverage Preferences
Current monthly health insurance premium (if known)
Monthly budget for Medicare-related coverage
Which cost approach best describes you?
*
I want the lowest monthly premium possible
I want predictable costs and fewer surprises
I want the best balance of premium and benefits
I am willing to pay more for broader flexibility
I am not sure yet
How do you feel about provider networks?
*
I am comfortable with networks if the cost is lower
I prefer more freedom to choose doctors
I need help understanding the difference
Unsure
Submit
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