Health Survey for Medicare Appointment
Please complete all questions based on your personal healthcare needs. Information you provided doesn't guarantee you for any health coverage. Pre-existing conditions may subject to specific policy underwriting guidelines; exclusions may apply. Any information provided to you is not intended to be legal or tax advice.

I have opted for assistance either in person, electronically or over the phone. I am providing consent for assistance while this consent remains indefinitely unless I choose to revoke such consent in the future either in writing or verbally to my agent/broker listed [Lin Lewis NPN# 18079192; llewis@invobh.com; 314-685-4428]

Email address *
Company
Your answer
First Name *
Your answer
Last Name *
Your answer
Address
Your answer
City *
Your answer
County *
Your answer
State *
Your answer
ZIP CODE *
Your answer
Phone *
Your answer
Date to start coverage *
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Email *
Your answer
Gender *
Date of Birth *
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Height *
Your answer
Weight *
Your answer
Do you smoke or use e-Cigarette *
Reason for the appointment *
What is your Medicare (A & B) ID card #? *
Your answer
Your Medicare (A & B) effective date on Your ID card? *
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Your current insurance ID card info, e.g. company name, plan name, benefits (copay,e tc); if no 2nd plan, put "none" *
Your answer
Your Prescription Drug Plan ID card info, e.g. insurance company name and copay? *
Your answer
Your current monthly premium? *
Your answer
One PERSON monthly premium $ within your budget to cover your healthcare costs that are not covered by Medicare, co-payment for doctor visits, prescriptions, STM in-home Services, Long Term Care, Final expenses, etc *
Do you take any medicine including Over the Counter (OTC) and prescribed Medicines? If Yes, please provide your medicine name and daily amount for price check in the next question. *
Name of prescriptions & daily amount for price check? If None, list NA *
Your answer
How many times have you seen a doctor in the past 12 month? if more than 1, go to next Question *
The purpose of your doctor each visit? *
Your answer
Your Physician name and office ph# for network check? *
Your answer
List your medical diagnosis, surgery and medical procedure performed past 10 years? *
Your answer
Est. 2019 Whole Household Income including Social Security, pension and survivor benefits, and alimony etc? *
Your answer
How many people on your tax return? If more than 1, list their full name, Date of Birth and address *
Your answer
Do you need dental coverage? *
Do you need vision coverage? *
Do you need critical illness & cancer coverage? *
Do you plan to have someone to be at your home to help you recover from a medical procedure e.g. Short Term in-home care Service (house cleaning, shopping, run errands) where Medicare doesn't cover? *
If you ever lose mobility one day, do you like to have Long Term Care Plan where Medicare doesn't cover, e.g. avg LTC facility $6,000/month x 2 years (~ $145K) *
Do you have Final Expense (funeral) in place? *
Do you have a Living Will notarized by Attorney to let your loved ones or friends know what kind of care you want in an event that you are unable to communicate your wishes because of a debilitating injury or illness? *
Who is your Durable Power of Attorney - gives named individuals the authorities to make important healthcare, financial and end-of-life decisions on your behalf (Notarized by an Attorney) *
Do you have a medical directive - let your loved one know how you would like your life to be saved or rest in peace? *
Are you planned for ~$150,000 (1 person) in reserve to pay for 2-year medical expense if you ever need to be hosted in a long-term care facility? *
If more than 1 person need advice on Medicare Plans, please complete a separate form *
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