CHI Franciscan - Medicare Patient Questionnaire

Medicare Patient Questionnaire

Completing this form is an extremely important step when preparing for Medicare eligibility as a patient of CHI Franciscan Health.
Patient Name *

First Name Last Name

Street Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number *
E-mail *
Medicare Eligibility
I plan to join Medicare Parts A and B upon turning age 65 I plan to join Medicare at a later time I am already Medicare eligible
Medicare Insurance Coverage

Please complete this section if you plan to join Medicare upon turning age 65
There are many different types of Medicare insurance. Please provide information regarding your anticipated Medicare insurance coverage.

I will be insured by a Medicare plan provided by my current or former employer (or my spouse's employer) I will be purchasing my own Medicare insurance plan I will be covered by Medicare and Medicaid (dual eligible) I am not sure
Please complete if purchasing your own Medicare insurance
How are you planning to research your insurance options?

Information found on the internet Advice from my friends or family Insurance agent or broker Insurance information mailed by Medicare plans
If you will be purchasing your own Medicare insurance or will be on Medicaid, it is important to understand that CHI Franciscan Health does not accept all insurance options available in the marketplace. Because many insurers contract with Medicare annually and network affiliations may change, we cannot be assured which plans will be accepted by CHI Franciscan Health from year to year. Please be sure to verify your chosen plan is accepted by your healthcare providers.
Would you like to be notified if there are any changes in the Medicare insurance plans accepted by CHI Franciscan Health?

Yes, please notify me of the changes
by email by mail by phone
Medicare Patient Resources

CHI Franciscan Health provides patients with a variety of free Medicare resources through our partnership with MedicareCompareUSA*. We encourage patients to take advantage of these important Medicare resources:
Medicare Educational Seminar

Informational seminars are held each month at CHI Franciscan Health. Seminars are designed to help patients understand their Medicare benefits and available Medicare insurance options. Seminars are educational in nature, so no Medicare plans will be marketed.
Explore your Medicare Insurance Options

Meet privately with a Medicare insurance agent at a convenient CHI Franciscan location or at your home. Receive unbiased comparisons of CHI Franciscan accepted Medicare plans including Medicare Supplements and Medicare Advantage plans.
Request Additional Information on Medicare Resources
I am interested in learning more about these free Medicare resources made available by CHI Franciscan Health and MedicareCompareUSA. Please have MedicareCompareUSA contact me with additional information as soon as possible. I understand that a licensed Medicare insurance agent may contact me and that I am under no obligation to purchase a Medicare plan.
HIPAA Authorization. I authorize CHI Franciscan Health, to disclose my name, phone number and address ("My Information") to MedicareCompareUSA and/or a licensed insurance agent for the purpose of contacting me to discuss Medicare services provided by MedicareCompareUSA. I understand that whether or not I sign this Authorization, my treatment, payment, health plan enrollment, and benefits eligibility will NOT be affected in any way. This Authorization will expire sixty days from the date signed. I understand that I have the right to revoke this Authorization by contacting the MCUSA Compliance Department at (503)610.6798. I understand that my revocation will be immediately effective upon my contact and applies only to future uses of My Information by MedicareCompareUSA. I understand that My Information may be subject to redisclosure by the recipient, and the privacy of My Information may no longer be protected by HIPAA.
Learn More About Your Medicare Insurance Options
Please keep me informed throughout the year of any changes to my insurance options as a Medicare recipient, and have a licensed insurance agent at MedicareCompareUSA contact me with additional information as soon as possible. I understand that I am under no obligation to purchase a Medicare plan.
Signed: *

First Name Last Name
Enter the message as it's shown *
*About MedicareCompareUSA

MedicareCompareUSA is an independent insurance agency and is not affiliated with the federal Medicare program. All services provided at no cost, as MedicareCompareUSA is paid directly by the Medicare plans accepted by CHI Franciscan Health.
CHI Franciscan Health partners with MCUSA Consulting to support Medicare patient communications
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Medicare Patient Questionnaire

Medicare Eligibility

Medicare Insurance Coverage

Please complete if purchasing your own Medicare insurance

Medicare Patient Resources

Medicare Educational Seminar

Explore your Medicare Insurance Options

Request Additional Information on Medicare Resources

Learn More About Your Medicare Insurance Options