Brookridge Beneifts Insurance Agency, Inc.

FORM-MEDICARE

Agent / Broker Information:

Name: Louie (Lew) Thompson, Agent / Broker

Name of Agency: Brookridge Benefits, Inc.

Local: (229) 337-4727 (or) Toll Free: (800) 297-0817

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Prequalification Questions

Individuals New to Medicare

Do you currently get a Social Security Check monthly?

YES

Are you going to sign up for Medicare?

YES

Have you received your Red, White & Blue-Medicare Card?

YES

Personal Information

Name * Required

Phone * Required

Address * Required

County * Required

Birthday * Required

Lead Source

Doctor / Medications / Conditions

What type of Health Coverage do you have now? (Marketplace, Group, Medicare or Medicaid) * Required

Do you have any of the following ? * Required

Diabetes

Heart Disease (or) Heart Failure

Lung Disorder (Ex: COPD)

Chronic Kidney Disease

NONE

Primary Care Doctor (First & Last) Name: (City & State) * Required

Medications & Pharmacy Name: (Name, Dosage) * Required

Pharmacy Name: * Required

Medicare Information

Not Required Before Discusssing plan with Agent.

Have you Recieved your Medicare Card?

Yes

Medicare (MBI) Number

PART A (Date)

PART B (Date)

LIS / Medicaid Information

Do they get extra help from the state with Medication Cost or Help with Part B

Social Security #

Do you get help from your state Medicaid or Low Income Subsidy?

Medicaid Information

Less Annoying CRM

Click the Link below to Complete the Medicare Scope of Apptointment:

https://www.cognitoforms.com/BrookridgeBenefitsInc/ScopeOfAppointmentConfirmationForm

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