Baptist Cigna Termination - Medicare Patient Survey

Baptist Memorial Health Care values you as a Medicare patient. We have partnered with MedicareCompareUSA, at no cost or obligation to you, to answer your questions and to assist you in selecting and enrolling in a Medicare plan that is right for you. Please complete the following survey so that licensed insurance agents can help you pick the best Medicare plan for you.

Name *

First Name Last Name

Address *

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

Phone Number *

Email *

example@example.com

Do you intend to remain a Baptist patient, or will you be changing your health care provider to retain your current Medicare plan? *

Yes, I intend to remain a Baptist patient. No, I will no longer be a Baptist patient, starting January 2020.

If you intend to remain with Baptist, how can we best support you in the process of reviewing your Medicare plan options for 2020? *

I would like information on scheduling an appointment with an agent. I would like to speak with an agent by phone. I have an agent helping me with Medicare insurance. I do not need any assistance.

I understand that a MedicareCompareUSA representative will contact me. I understand that all MedicareCompareUSA services are provided at no cost or obligation. Should I enroll in a Medicare plan using MedicareCompareUSA, I understand that MedicareCompareUSA will be paid directly by the Medicare plan I choose.

Signed: *

First Name Last Name

MedicareCompareUSA is an independent insurance agency not affiliated with the federal Medicare program. Baptist Memorial Health Care receives no financial benefit when patients utilize the services of MedicareCompareUSA. All services are provided at no cost and without obligation, and Medicare beneficiaries are free to contact each Medicare plan directly, work with any qualified insurance agent, or access Medicare plan information by calling 1 (800) MEDICARE or online at www.medicare.gov.

Please answer the following questions: