New Medicare Client Intake Form Fill out this form ahead of time to make your appointment as smooth as possible New Medicare Client Intake Form Your Personal InformationName(Required) First Middle Last IMPORTANT NOTE: Enter your name exactly as it appears on your Medicare cardDate of Birth MM slash DD slash YYYY Cell Phone(Required)Home PhoneEmail Address Home 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 Your Medicare CardDo you have your Medicare card already?(Required) Yes No (skip to next section) Medicare Number Part A Effective Date MM slash DD slash YYYY Part B Effective Date MM slash DD slash YYYY Your Medical InformationDoctors and Other ProvidersProvider NameClinic Name Add RemoveStart with your Primary Care Provider and list as many others (dentist, specialists, etc) as necessary (use the + button on the right).Prescription MedicationsRx Name (e.g. simvastatin)Dosage (e.g. 10mg)Quantity (e.g. 30)Frequency (e.g. every month) Add RemoveYou don't have to provide this information, but it helps us find the best drug plan for you. Use the + button on the right to add more lines.Are You a Robot?NameThis field is for validation purposes and should be left unchanged.
