Medicare Planning Questionnaire
1. CLIENT INFORMATION
First name
Last name
Birthday
Month
Day
Year
Phone
Email
Home Address
Country/Region
Address
City
Zip / Postal code
2. MEDICARE STATUS
Already receiving Social Security?
Yes
No
Medicare Part A:
Active
Pending
Not Applied
Effective Date:
Medicare Part B:
Active
Pending
Not Applied
Effective Date:
3. EMPLOYMENT & CURRENT COVERAGE
Currently Working?
Yes
No
Employer Size
Under 20
20 or more
Current Health Coverage:
Yes
No
COBRA Coverage:
Yes
No
SOA signed:
Yes
No
Retirement date (if applicable):
4. PRESCRIPTION DRUGS
Do you take any medications?
Yes
No
List of medications collected?
Yes
No
Preferred pharmacy
Interested in mail order?
Yes
No
5. Doctors & Healthcare
Primary Care Provider:
Specialists:
Preferred Hospital:
6. FINANCIAL & ASSISTANCE
Do you qualify for Medicaid?
Yes
No
Concerned about IRMAA?
Yes
No
Extra Help (Low Income Subsidy):
Yes
No
7. PLAN INTEREST
Interested in:
Medicare Advantage
Medigap
Unsure
Travel frequently?
Yes
No
Budget considerations?
Yes
No
Any notes:
Submit
Medicare Planning Questionnaire
