MEDICARE Health Intake Form
Please select below:
A
Current Client
B
New Client
How did you hear about us?
Full Name
*
Address
Zip Code
*
Phone #
*
County
*
Date of birth
*
/
/
Email Address
*
Preferred method of communication:
*
Email
Phone
Medicare #
This is needed to enroll-number found on your red/white/blue card
Medicare Part A Start Date:
/
/
Leave blank if unsure
Medicare Part B Start Date:
/
/
Leave blank if unsure
Current Coverage
What carrier do you have now?
Date Coverage Ended or Will End
/
/
If unsure just leave blank
Current Doctors
*
Current Pharmacy
*
Please list current and an alternative pharmacy also!
Prescriptions currently taking-DRUG / DOSAGE / HOW OFTEN:
*
Example: Fluoxetine /20mg /daily. We use this to look up formularies with each carrier.
Any other information to share?
Agent working with:
*
Choose One
Rachel Lauser
Audra Moore
Unsure
Your form has been saved. You can complete it using this link within %(day)s days.
Copy
Submit
