Medicare Intake Form

1. Client Demographics & Identification

Full Legal Name *Date of Birth (DOB) *Primary Phone *Email AddressDriver's License / ID #Social Security # (SSN) *Address *County of Residence

Do you currently work?

Yes No

Do you have health insurance through work or any other source?

Yes No

Any Health Condition / DiagnosisReferral Source

Do you have a spouse?

Yes No

2. Medicare Coverage & Current Policies

Medicare ID (MBI) #Medicaid ID #

Current Carrier / PlanI don’t know

Coverage Requested

3. Doctors & Specialists List

Doctor / Provider NameSpecialty / RoleClinic / Practice NameCity, State

4. Prescription Medications (Rx) List

Prescription Drug NameDosage / StrengthTimes a dayPreferred PharmacyRx Form

5. Preferred Time To Contact You

Is there a specific time that works best for you?Case Notes & Client Goals

By submitting this form, I give ALC Insure permission to contact me by phone call, text message, or email regarding Medicare insurance plans, coverage options, enrollment assistance, and related services. Consent is not a condition of enrollment or the purchase of insurance. Message and data rates may apply. I may withdraw my consent at any time.