Medicare Coverage Intake Form

First Name *

Last Name *

Date of birth *

Zip Code *

Email *

Phone *

County

Medicare Number

Part A Effective

Part B Effective

Do you have Medicare Part D?

Do you qualify for assistance?

Do you have any other forms of insurance?

QI-1 / SLMB / QMB

LIS

CHRONIC

SPECIFIC PLAN MEDICAID #

Do you have a Primary Care Physician (PCP)?

Name of Primary Care Physician (PCP)?

How many different prescriptions are you taking?

Would you be willing to switch from a name brand to a generic for a lower out-of-pocket cost?

Name of Prescriptions

Are dental benefits an important factor in your next health plan?

Do you have a dentist that you visit regularly?

Name of other Doctors, Hospitals, Dentists, Pharmacies

Are fitness memberships and healthy lifestyle benefits important to you?

Are vision benefits an important factor for you?

Are hearing benefits an important factor in your next health plan?

Are you interested in any of these other benefits?

Do you have a Power of Attorney? If so, who?

Do you currently use any tobacco products?

What are the things you like about your current plan?

If there were some things, you could change with your current plan what would they be?

Source of business

Date of appointment

SOA dated at least 48hrs in advance. If “no” reason?

Products discussed

If other health related products, list them here

Names of who was in attendance

Identification Documents