Health Intake Form

Medicare Questionnaire

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.
Full Name*

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number*

Country CodeArea CodePhone Number
Email Address*
example@example.com
Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (if applicable)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Medicare #
Do you have Original Medicare Part A?*

YesNo
If yes to above, when did/does your Part A start?*

MonthDayYear
Date
Do you have Original Medicare Part B?*

YesNo
If yes to above, when did/does your Part B start?*

MonthDayYear
Date
Optional Additional Information

Please select the following items that apply to you:

	Yes	No
Do you have a group health plan?
Do you qualify for Medicaid?
Do you qualify for Extra Help?

Do you have a Medicare Supplement or Medicare Advantage Plan?
(Provide details on the space above.)
Do you have a stand alone Part D Plan?
(Provide details on the space above.)
What would you like to change about your current Medicare plan or Drug plan?
(Provide details on the space above.)

What prescriptions (not OTC) do you take regularly (include dosage/frequency)?

	Name	Dosage	Frequency	30 or 90 day refill
1
2
3
4
5
6
7
8
9
10

What is your primary pharmacy and address?
(Provide details on the space above.)
What doctors do you see on a regular basis?
(Provide details on the space above.)
Medicare Card Photo Upload

Please upload a copy of your Medicare Card (red, white, and blue).
File Upload

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