Lourie Life and Health

Medicare Questionnaire

Name (Required) *

First Name Last Name

Birth Date

Date

Phone Number

Area Code Phone Number

Email

example@example.com

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

MyMedicare.gov

Do you have an account on mymedicare.gov? If so, please provide your credentials below:

Username

Password

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.

Do you have Original Medicare Part A?

Yes No

When did/does your Part A start?

Date

Do you have Original Medicare Part B?

Yes No

When did/does your Part B start?

Date

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)

Do you have a stand alone Part D Plan? (Provide Details)

What would you like to change about your current Medicare plan or Drug plan?

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

Name

Dosage

Frequency

1

2

3

4

5

6

7

8

9

10

What is your primary pharmacy and address?

What doctors do you see on a regular basis?

Are you working with any of the following agents?