Thank you for scheduling

your Medicare appointment!

Please complete this short intake form so we can review your situation and make the best use of our time

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Agency Intake Form

Please complete this form so I can review your information before our appointment.

About You:

First Name *

Last Name *

Phone *

Email *

Date of birth *

Helps determine Medicare, ACA & other eligibility

Type of coverage interested in?

Medicare Details (if applicable)

Registered with Medicare?

Do you have your Medicare Card?

Yes

No

Not Sure

Medicare ID (MBI) *

Part A Effective Date

Part B Effective Date

Additional Eligibility Information

Do you have a Veteran Status?

Yes

No

---> Includes VA, CHAMPVA, TRICARE, or Veteran spouse

VA / TRICARE Coverage

Do you receive Medicaid?

Yes - I have Medicaid

Awaiting Approval

No

Medicaid Number

Coverage Information

Are you currently covered?

Current Coverage

Including Spouse and/or Dependents?

Who else will be included?

Best Contact Method

Appointment Preference

Anything else you'd like us to know?

By checking this box, I agree to receive appointment-related and service-related messages, including reminders, confirmations, and important updates. Message frequency may vary. Msg & data rates may apply. Reply HELP for help or STOP to opt out.

I consent to receive informational and marketing messages about Medicare and related insurance services. Msg & data rates may apply. Reply HELP for help or STOP to opt out.

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