Medicare Information Form for Current Clients Fill out this form ahead of time to make your appointment as smooth as possible Your Personal InformationSince you are a current client of Ulness Health, we should have your contact information on file, so you only need to fill out the (non-required) information below if it has changed in the past two years.Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Email Address(Required) Cell PhoneHome PhoneHome Address Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code CountyCounty (Outagamie, Winnebago, Calumet, etc.) Tax Filing Status Individual Joint Income (Individual Filer)less than $103K$103K - $129K$129K - $161K$161K - $193K$193K - $500Kgreater than $500KAdjusted gross income (AGI) from your most recent tax returnIncome (Joint Filer)less than $206K$206K - $258K$258K - $322K$322K - $386K$386K - $750Kgreater than $750KAdjusted gross income (AGI) from your most recent tax returnNotes on Changes to Personal InformationYour Medical InformationPlease enter your current providers and medications, so we can find the best plan for youHospital/Health System Add RemoveList the hospital(s) and/or health system(s) you want to have in your plan's network. Use the + button on the right to add rowsDoctors and Other ProvidersProvider NameSpecialtyClinic Name Add RemoveList the providers you want to have in your plan's network. Start with your Primary Care Provider. Add other providers (specialists, dentist, etc.) using the + button on the rightPharmacy Add RemoveList the pharmacies you want to have in your plan's network. Use the + button on the right to add rowsPrescription MedicationsRx Name (e.g. simvastatin)Dosage (e.g. 10mg)Refill Quantity (e.g. 30)Refill Frequency (e.g. every month) Add RemoveUse the + button on the right to add more linesPrescription Medications I don't take any prescription medications Notes on Changes to Medical InformationYour Plan PreferencesThoughts on Current PlanHow do you like your current Medicare plan? Is there anything you would change? What are you looking for in a different plan?What kind of health plan design are you looking for? Lower premium plan with higher co-pays Higher premium plan with lower co-pays I'm not sure Other (use "Notes" box below) Do you require hearing, dental, and/or vision coverage? Yes No Do you have any specific health care needs? None Durable medical equipment (diabetes supplies, walker/cane, CPAP machine, etc.) Physical therapy Mental health therapy Chiropractic/Acupuncture Other (use "Notes" box below) Notes on Plan PreferencesLet us know if there's anything specific you are looking for in a plan that wasn't covered aboveAgent InformationAgent(Required)John Ulness NPN: 6530356Marit Ulness NPN: 15887658Erik Ulness NPN: 15952162Don Bachaus NPN: 6493416James Boland NPN: 20305616Who are you meeting with?Robot CheckAre You a Robot?NameThis field is for validation purposes and should be left unchanged.
