Medicare Insurance

Medicare

PART A.

1. Name of Beneficiary (Applicant)

Last Name

2. Email Address

3. Date Of Birth

4. Address

Address Line 1

City

State

Zip Code

5. Phone/Mobile

6. Do you have children?

If yes, do any of your children fall into the following age categories?

Do you smoke?

MEDICARE INFORMATION:

7. Do you have Medicaid?

Medicaid Card Number

8. Do you have VA or Tricare benefits?

Tricare

None

9. Are you enrolled in Medicare?

Medicare Card Number (Please do not use hyphens or dash)

Effective date: Part A (Hospital)

Effective date: Part B (Medical)

Do you have any additional coverage, such as a supplement plan or a prescription drug plan? Select one or both, if applicable:

Supplement Plan (A, B, D, G, K, L, M, N, C, F)

Prescription Drug (Stand alone Plan)

None

Please provide the type of supplement plan and the monthly premium amount:

Please provide the monthly premium amount:

Would you like to provide an Emergency Contact?

If yes, please enter the name of your Emergency Contact:

Could you please share why you don't have Medicare coverage at this time?

Did you know you can get penalized? Don't risk unnecessary penalties! We're here to help you enroll and save!

VERY IMPORTANT:

To help us focus on your most important Medicare needs and to ensure your Medicare coverage aligns with your current healthcare or if you decide to change plans, please provide the following details:

✅ The following will further assist us in better understanding your needs.

10. What benefits are most important to you when it comes to your Medicare plan?

Please share any additional information you'd like us to know. This will greatly assist us in taking care of your needs.

PART B.

Doctors' Information:

✅ While we make every effort to ensure that your doctors and prescriptions are in-network at the time of enrollment for the upcoming year, please keep in mind that providers and prescription medications may move in and out of network throughout the year.

✅ If you find that any of your doctors or prescriptions are no longer covered, I recommend discussing it with your doctor's office to explore options for staying in-network. This will help protect you from unexpected costs and ensure continuous coverage.

11. How many doctors are currently involved in your care (MD's only)?

1. Doctor's Name

Type of Doctor

Type of Specialist

Doctor's Address

Address Line 1

City

State

Zip Code

1. Doctor's Name

Type of Doctor

Type of Specialist

Doctor's Address

Address Line 1

City

State

Zip Code

2. Doctor's Name

Type of Doctor

Type of Specialist

Doctor's Address

Address Line 1

City

State

Zip Code

1. Doctor's Name

Type of Doctor

Type of Specialist

Doctor's Address

Address Line 1

City

State

Zip Code

2. Doctor's Name

Type of Doctor

Type of Specialist

Doctor's Address

Address Line 1

City

State

Zip Code

3. Doctor's Name

Type of Doctor

Type of Specialist

Doctor's Address

Address Line 1

City

State

Zip Code

1. Doctor's Name

Type of Doctor

Type of Specialist

Doctor's Address

Address Line 1

City

State

Zip Code

2. Doctor's Name

Type of Doctor

Type of Specialist

Doctor's Address

Address Line 1

City

State

Zip Code

3. Doctor's Name

Type of Doctor

Type of Specialist

Doctor's Address

Address Line 1

City

State

Zip Code

4. Doctor's Name

Type of Doctor

Type of Specialist

Doctor's Address

Address Line 1

City

State

Zip Code

For 5 or more, please list all the Doctors' names, addresses and types:

12. Do you take any medications?

Yes

13. How many prescription medications are you currently taking?

1. Type of Medication:

Dosage

Reason for Taking Medication:

Frequency

Form of Medication

1. Type of Medication:

Dosage

Reason for Taking Medication:

Frequency

Form of Medication

2.) Type of Medication:

Dosage

Reason for Taking Medication:

Frequency

Form of Medication

1. Type of Medication:

Dosage

Reason for Taking Medication:

Frequency

Form of Medication

2. Type of Medication:

Dosage

Reason for Taking Medication:

Frequency

Form of Medication

3. Type of Medication:

Dosage

Reason for Taking Medication:

Frequency

Form of Medication

1. Type of Medication:

Dosage

Reason for Taking Medication:

Frequency

Form of Medication

2. Type of Medication:

Dosage

Reason for Taking Medication:

Frequency

Form of Medication

3. Type of Medication:

Dosage

Reason for Taking Medication:

Frequency

Form of Medication

4. Type of Medication:

Dosage

Reason for Taking Medication:

Frequency

Form of Medication

For 5 or more, please list all your medications, dosages, reasons, frequency and forms:

Please indicate if there is a copay for any of your prescription medications and provide details of the amount if applicable.

Please still provide us with the name and address of a preferred pharmacy near your zip code so we can check if it’s in network and ensure your protection, should you ever need it in the future.

Pharmacy Name

Pharmacy Address

Preferred Pharmacy and Address:

Is it a Digital Pharmacy?

Pharmacy Name

Pharmacy Address

✅**If you have already completed or scheduled your Medicare Comparison Overview Appointment, please disregard the following information.

✅**Once we receive your information, please expect a response within 24 hours to schedule your Medicare Comparison Overview Appointment with me or one of my experts.

✅Please be advised that once your Medicare profile is completed with the information you provided, a Scope of Appointment (SOA) form will be sent to you via email. This form must be signed and returned before we can discuss any details of your Medicare plan in order to comply with CMS requirements. This step ensures that we, as agents, provide you with proper care when explaining your plans and options.

✅Thank you for your consideration; we truly appreciate it! If you have any questions, please let us know. We are here to assist you in any way we can.

☆ At Family Comes First Insurance Agency, your privacy is important to us, and we are committed to assisting you while protecting your personal information, as stated under HIPAA client protection. By providing your personal information, you consent to us contacting you for your insurance needs, including answering your questions, reviewing insurance plans, and providing quotes for the plans you choose. Once we apply for your chosen insurance plan and you are approved, we will share your details with the specific insurance carrier.

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Your Medicare Questionnaire

PART A.

MEDICARE INFORMATION:

Did you know you can get penalized? Don't risk unnecessary penalties! We're here to help you enroll and save!

VERY IMPORTANT:

PART B.

Doctors' Information:

✅**If you have already completed or scheduled your Medicare Comparison Overview Appointment, please disregard the following information.

✅**Once we receive your information, please expect a response within 24 hours to schedule your Medicare Comparison Overview Appointment with me or one of my experts.

✅Thank you for your consideration; we truly appreciate it! If you have any questions, please let us know. We are here to assist you in any way we can.