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Personal Information
Salutation:
Mr.Mrs.Ms.
First Name:
MI:
Last Name:
Date of Birth:
Email:
Telephone:
Street Address:
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Questionnaire
Are you eligible for Medicare or Medicare Disability?
YesNo
Are you on Medicaid or Medicare Drug Assistance?(State or Federal help)
YesNo
Medicare Effective Date
Hospital (Part A)
Medical (Part B)
What do you currently have to help you with your prescription drugs?
Does your drug plan also cover your doctors and hospitals?
YesNo
What do you currently have to help you with your doctor and hospital bills?
Who helps you with your insurance / financial needs (such as Power of Attorney, son, daughter, etc.)?(include contact info if necessary)
Comments:Please help us understand your situation.