New Medicare Client Intake Form Fill out this form ahead of time to make your appointment as smooth as possible Your Personal InformationName(Required) First Middle Initial Last Date 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 CountyCounty (Outagamie, Winnebago, Calumet, etc.)Tax Filing Status Individual Joint Income (Individual Filer)less than $106K$106K - $133K$133K - $167K$167K - $200K$200K - $500Kgreater than $500KAdjusted gross income (AGI) from your most recent tax returnIncome (Joint Filer)less than $212K$212K - $266K$266K - $334K$334K - $400K$400K - $750Kgreater than $750KAdjusted gross income (AGI) from your most recent tax returnYour Medicare CardDo you have your Medicare card already?(Required) Yes No (skip to next section) Medicare NumberPart A Effective Date MM slash DD slash YYYY Part B Effective Date MM slash DD slash YYYY Your Medical InformationHospital/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 Your Plan PreferencesWhat kind of health plan design are you looking for?(Required) 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?(Required) Yes No Do you have any specific health care needs?(Required) None Durable medical equipment (diabetes supplies, walker, CPAP machine, etc) Physical therapy Mental health therapy Chiropractic/Acupuncture Other (use Notes box below) Select all that applyAre you a veteran?(Required) Yes No 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?How did you first hear of Ulness Health?Referred by Family/FriendReferred by AdvisorInternet SearchAppleton Farm MarketBuilding SignsMedicare Workshop/PresentationOtherName of Family/FriendName of AdvisorNotes on "Other"Robot CheckAre You a Robot?NameThis field is for validation purposes and should be left unchanged.
