Medicare Advantage Questionnaire

*You are not required to provide any private, protected health information (PHI). The below requested information is for use by Mark E. Werner, MSFS, CFP, RICP, RICP, CLU, ChFC only to help you make an informed plan decision and will not be shared with any third party.

You will be providing the PHI voluntarily and without coercion from Mark E. Werner, MSFS, CFP, RICP, CLU, ChFC.*

Name *

First Name Last Name

If you already filled out your Medicare Part D Questionnaire, you may skip down to the questions about your Doctors.

Email

example@example.com

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Date of Birth

Medicare Claim # (found on your Medicare card)

Part A Effective Date

Part B Effective Date

Who is your Primary Care Physician + zip code where your doctor is located?

List any specialists you see. Please include what type of specialist, and the zip code your specialist is located. Example: Dr Kevin Smith, cardiologist, 12345

Which hospital do you prefer? *

Are you interested in Dental & Vision options? *

YES NO I'm not sure

Are you on Medicaid? *

YES NO YES, and on a spend-down

IF YOU ANSWERED "YES, and on a spend-down", how much $ per month?

Are you on Low Income Subsidy for your prescriptions? *

YES NO I'm not sure