Medicare Intake Form

First Name *

Last Name *

Date of birth *

Zip Code *

Email *

Phone *

County

Medicare Number

Part A Effective

Part B Effective

Do you have Medicare Part D?

Yes
No
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Do you qualify for assistance?

Medicaid
LIS
SPAP
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Do you have any other forms of insurance?

Group
COBRA
VA
ChampVA
Tri-Care
ACA
Indian Health Services
Med Sup
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QI-1 / SLMB / QMB

LIS

CHRONIC

SPECIFIC PLAN MEDICAID #

Do you have a Primary Care Physician (PCP)?

Yes
No
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Name of Primary Care Physician (PCP)?

How many different prescriptions are you taking?

Would you be willing to switch from a name brand to a generic for a lower out-of-pocket cost?

Yes
No
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Name of Prescriptions

Are dental benefits an important factor in your next health plan?

Yes
No
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Do you have a dentist that you visit regularly?

Yes
No
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Name of other Doctors, Hospitals, Dentists, Pharmacies

Are fitness memberships and healthy lifestyle benefits important to you?

Yes
No
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Are vision benefits an important factor for you?

Yes
No
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Are hearing benefits an important factor in your next health plan?

Yes
No
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Are you interested in any of these other benefits?

Food Cards
OTC
Transportation
Part B Premium Reduction
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Do you have a Power of Attorney? If so, who?

Do you currently use any tobacco products?

Yes
No
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What are the things you like about your current plan?

Copays
Provider/Network
Inpatient
Outpatient
OTC
D/V/H
Fitness
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If there were some things, you could change with your current plan what would they be?

Source of business

BRC
Phone-In
Social Media
Internet Landing Page
Referral
Lead Vendor
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Date of appointment

SOA dated at least 48hrs in advance. If “no” reason?

Products discussed

MA
Part D
Med Sup
Other Health Related Products
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If other health related products, list them here

Names of who was in attendance

Identification Documents