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WELCOME TO OUR
MEDICARE QUESTIONNAIRE
Medicare New Questionnaire
Please provide these optional details that will help us better serve you. Your contact information and basic questions will help us better understand your needs. We represent most Advantage, Drug and Supplement Plans on the market.
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Name
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First
Last
Spouse Name
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First
Last
Phone Number
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Email
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Address
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Line 1
Line 2
City
State
Zip Code
Country
Current Insurance (You and your spouse)
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Medicare Advantage Plan
Medicare Supplement & Drug Plan
Original Medicare Only
New to Medicare (Turning 65)
Over 65, retiring from work plan
Medicare / Medicaid DSHS
Health Insurance on WA Health Exchange
Not Sure
WHAT MEDICATIONS DO YOU TAKE?
Types of Medication you take:
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Generic Drugs
Brand Name Drugs
None
If you take medication, please list the Name, Dosage and Frequency
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WHO ARE YOUR DOCTORS / SPECIALISTS?
We would like to find doctors that accept the plans you desire. Please list their name and the clinic they work at. (Example: Dr Dave Smith at Everett Clinic)
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Any additional Comments?
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By submitting this form, you consent to a follow-up call by Birdseye Financial and their representatives.
I agree to receiving marketing and promotional materials
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