Medicare Pre-Enrollment Questionnaire

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Medicare Pre-Enrollment Questionnaire

"*" indicates required fields

Date*

Referred By

Client Information

Primary Party Information

Name*

Phone*

DOB*

Email*

Address*

Street Address City ZIP Code

Is your mailing address different from your physical address?**

Yes

Mailing Address*

Street Address City State ZIP Code

Medicare #

(A) Effective Date

(B) Effective Date

Primary Care Physician

Spouse Information

Name

Phone

DOB

Address

Street Address City State ZIP Code

Is your spouse's mailing address different from their physical address?

Yes

Mailing Address

Street Address City State ZIP Code

Medicare #

(A) Effective Date

(B) Effective Date

Primary Care Physician

Pathway to a Decision

Take a few minutes to complete this simple worksheet. When selecting the right individual health insurance policy for you, your doctors and your prescription drugs are important factors. The information you provide here will help us work together to choose the ideal plan(s) to meet your coverage needs and work within your budget.

1. What is your current healthcare coverage?*

Employer

Individual

Not Covered

2. Is your spouse and/or family enrolled in the same plan?*

Yes

3. Are you enrolled in both Medicare Part A and Part B?*

Yes

I Don’t Know

4. Do you currently take any prescription drugs?*

Yes

No – go to question #6

What is the name of the pharmacy where you usually fill your prescription drugs?*

5. What prescriptions do you fill most often

Drug Name

Dosage

Number of Pills Per Month

Drug Name

Dosage

Number of Pills Per Month

Drug Name

Dosage

Number of Pills Per Month

Why do you see your current doctor(s)? Check all that apply.*

I see my doctor(s) mostly for preventive care or an occasional health problem

I see my doctor(s) for one chronic (long-lasting) condition or multiple health issues

I see my doctor(s) for more than one chronic (long-lasting) condition or if I need a major procedure

7. Rank the four items below based on what’s most important to you in selecting your health coverage.

Keep in mind that “1” is the most important and “4” is least important. Be sure to enter a different number (1, 2, 3, or 4) on each item.

Low monthly premium*

Physician choice*

Low payment when admitted to the hospital*

Low payment for doctor office visit*

8. Who are the doctors you see most often?

Name

Address

Specialty

Name

Address

Specialty

Are you satisfied with your current care/doctors?*

Do you travel frequently? (Inside or outside the USA)*

Yes

9. Are you Diabetic? If so, do you use any treatment?*

Yes: Type A

Yes: Type B

Treatment (If Any)

10. Do you or your spouse expect to have multiple hospital admission in the next 12 months?*

Yes

11. Do you or your spouse expect to have Infusion Therapy within the next 12 months?*

Yes

12. What is your preferred method of contact?

Work Phone

Cell Phone

Other

12. I give Michigan Planners permission to reach out via preferred contact method.

Yes