Medicare World

Worlds/ Medicare/ New Client Intake

Michael

Medicare — New Client Intake

New Medicare Client

Fill this out during the call. Fields marked * are required. All data saves directly to the CRM contact record.

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Contact Information

Basic identity and contact details

First Name *

Last Name *

Date of Birth *

Phone *

Street Address

City

State

Zip Code

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Medicare Identity

Medicare card numbers and effective dates

Medicare Beneficiary ID (MBI)

Medicaid ID (if applicable)

Medicare Part A Effective Date

Medicare Part B Effective Date

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Eligibility & Status

Current coverage and Medicare eligibility

Currently Enrolled in Medicare?

Has Medicare Part A & Part B?

Current Coverage Type

Medicare Status

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Primary Care Physician

PCP details for network and formulary verification

PCP Name

PCP Phone

Medical Group / Practice

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Specialists

Other doctors seen regularly beyond PCP

Specialist 1 — Name

Specialist 1 — Specialty

Specialist 2 — Name & Type

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Prescriptions

Current medications to verify formulary coverage

Medication 1

Dosage

Frequency

Medication 2

Dosage

Frequency

Medication 3

Dosage

Frequency

Medication 4

Dosage

Frequency

Medication 5

Dosage

Frequency

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Preferred Pharmacy

In-network verification for plan selection

Pharmacy Name & Location

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Current Plan Info

Existing Medicare plan details — if already enrolled

Medicare Carrier

Plan Name

Plan ID / H Number

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Source & Notes

How they found us and any call notes

Referred By

Lead Source

Agent Notes

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Client Record Created

All information has been saved to the CRM.

Tags applied: medicare-client • medicare-lead • veronica-current-book

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