COMPLETE THIS FORM SO WE CAN VERIFY
YOUR ELIGIBILITY AND BETTER SERVE YOU
*
indicates required
Name:
Email:
Comment:
First Name
*
Middle Initial
Last Name
*
Phone
*
Email Address
*
Date Completing Form
Cell Phone
Medicare Member ID: (from Medicare card)
*
(Above number is a 9 Digit Number followed by a letter)
Effective Date – PART A
Effective Date – PART B
Medicaid Number (if applicable)
(Above number is a 9 Digit Number starting with a 5 or 6)
MEDICARE PLAN YOU CURRENTLY HAVE (if applicable)
Primary Doctor
Primary Doctor’s Phone
City of Primary Doctors Office
Special Programs may be available if you meet any
Diabetes
Cardiovascular Disorder
ESRD – End Stage Renal Disease-Kidney Failure Requiring Dialysis
Low Income Subsidy
Medicaid Recipient
