Over 65 Medicare Intake Form

First name & Last Name & Gender

Full Address

Full Address with Zip Code

Email & Phone Number

Birthdate, Best Time/Days to contact

Current Coverage, Local Hospital

Medicare ID Number (Optional), Medicare Part A Effective Date (Optional), Medicare Part B Effective Date (Optional)

Medicare ID Number (Optional),

Medicare Part A Effective Date (Optional), Medicare Part B Effective Date (Optional)

Premium, Deductable, Annual Income

Doctors/Specialist

Please List Doctors/Specialist

Perscriptions (please include RX name, dosage, conditions, and preferred pharmacy)

(please include RX name, dosage, conditions, and preferred pharmacy)

Do you have a preferred plan? (MediGap, Advantage, PPO, HMO, I Don't Know, or Other)

(MediGap,

Advantage,

PPO,

HMO,

I Don't Know, or

Other)

Customized Protection