All Things Insurance Benefits

Client Needs Assessment Form

CNA

First Name *

Middle Name

Last Name *

Nickname

Date of birth MM-DD-YYYY *

Email (CONFIRM EMAIL BY REPEATING OUT LOUD) *

Cell Phone ONLY (NO LANDLINES) *

Gender *

Male
Female
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Address 1 (residential address )include Apartment # *

City *

State *

Postal code *

County *

Mailing Address 1 *

Mailing Address 2 ( Unit #, Ste, etc)

Mailing Address City

Mailing address State

Mailing address Zip Code

Who Referred Us To You? We Want To Thank Them! *

Tobacco User? *

No
Yes
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What's Important To You?

Please Check All That's Important To You *

Stand-a-lone Medicare Prescription Drug Plan (D)
Medicare Supplement (Medigap)
Medicare Advantage Plan (C)
Dental/Vision/Hearing
Hospital Indemnity - A Plan That Pays You Cash For Specific Health Event
Life Insurance/Final Expenses
Retirement Planning
Long-Term Care Insurance/Extended Care Planning
Increase monthly cashflow/Annuities For Immediate Lifetime Income
Group LTCi/Medicare/Health Insurance
Health Insurance For Unde Age 65/ACA Healthcare
Need Guidance For A Senior Parent or Loved-One
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Do Any Of These Apply to You? *

No - None of these Apply
Federal Retirement Benefits
State Retirement Benefits
State Teachers Retirement System (TRS)
Tricare
VA (Veterans Affair)
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What would you like to accomplish in your appointment. *

Flexibility/Choices OR Budget - I know both are important. Which is Most Important To You? *

Flexibility/Choices/Higher Premium/Lower Costs
Budget/Low Premium/Higher Out of Pocket Costs
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Do you have a deadline to ENROLL? If Yes, what date do you need your insurance to be effective?

Do You Travel Outside The US? Yes or No *

Emergency Contact Name, Cell Number, Relationship *

Text

Are You Collecting Social Security? Now or this year? *

Yes
No
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Retired? Or Plan To Retire THIS YEAR? *

Yes
No
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Marital Status: Single/Widow/Married/Domestic Partner/Divorced. Will Spouse/Partner Apply?

Single
Widow
Married
Domestic Partner
Divorced
Single w/room-mate
Single wi/room-mate 60 and over
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Does Your Partner Need Medicare Help?

Yes
No
N/A
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How Familiar With Medicare *

Not familiar
A little familiar, but I don't know where to start
I have a pretty good idea
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Do You Have Medicare? *

Yes
No
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Medicare ID (We need to confirm your eligibility)

Do You Have Your Medicare Card? In Your Possession - Yes or No

Yes
No
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Medicare Part A Effective Date

Medicare Part B Effective Date

Tell Me About Current Health Insurance *

I'm already on Medicare
I have coverage through my employer/union
I have an individual plan through the marketplace
Original Medicare (Part A Only)
Original Medicare (Part A and B)
I'm on COBRA
I have Medicaid
I don't have health insurance
HMO Medicare Advantage
PPO Medicare Advantage
Original Medicare plus Medicare Supplement
Original Medicare plus Prescription drug plan
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Name of Your Current Health Plan/Member ID/Start & End Date *

Current Cost Per Month?

Are you familiar with the differences between Medicare Advantage and a Medicare Supplement?

Yes
No
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What Do You ENJOY about current plan? What do you want To CHANGE about your CURRENT plan? *

Do You Receive Medicaid? QMB? LIS? Recent changes? *

Yes
No
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Any Challenges Paying Bills? If yes, I will recommend some resources for you. Like Medicare Extra Help. *

Yes
No
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If YES, Provide Your MEDICAID ID#

For Medicare Advantage Clients - OR Those seeking an Advantage Part C - What Benefits are you Seeking? OTC Over The Counter ? Transportation? Fitness? Giveback ($ put back into your social security)?

For Medicare Advantage Clients - Or those seeking an Advantage Part C - Which are you seeking....HMO (keeps more money in your pocket with some inconvenience like referrals from PCP for specialist or PPO (cost more but gives you the flexibility to choose in network or out of network medical providers at a higher cost)?

How Many Doctors Must You Keep? COUNT ALL OF YOUR MUST KEEP DOCTORS. PCP/Cardiologist/GI/Oncologist/Etc *

None - 0
PCP Only
1-3 Physicians (PCP and/or Specialty Drs.)
4-7 Physicians (PCP and/or Specialty Drs.)
8+ Physicians (PCP and/or Specialty Drs.)
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Are You Seeking A Plan Where Your Current Primary Care Dr/NP. is IN Network? If NONE, put No. *

Yes
No
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Name of your Current Primary Care Physician and Specialty Doctors- First Name, Last Name, Address, and Zip Code - If you DO NOT have a Primary Care Dr. put NONE.

Preferred Hospital for scheduled medical procedures (If applicable)

Current and preferred Pharmacy Name and Zip Code *

Would you like us to look up any Rx you may take to verify if & how they may be covered by the plan recommended? RX Medication List - Name on bottle, dosage, TAB or CAPSULE, frequency, and reason taking

Any Recent Prescription RX Medication Changes? Yes or No

Yes
No
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OK with GENERIC Drugs To SAVE $$$? *

Yes
No
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OK with different PHARMACY to SAVE $$$? OR Do you prefer to stay with your current pharmacy? *

Yes
No
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If using an outside source for RX, please list names; Example; GoodRX, The Canadian MedStore, Amazon, Drug Manufacturer GRANT, etc. THE COST OF THESE DRUGS WILL NOT COUNT TOWARD MAX OUT OF POCKET

Chronic Special Needs Plan Eligibility - ***Information below is optional however carriers offer plans designed for specific health conditions like diabetes, congestive heart failure, cardiovascular disease, COPD, and ESRD. If you believe one of these types of plans could benefit you, I'd be happy to review the eligibility.

Height *

Weight *

Answering is optional, however there are plans designed to help specific health conditions

Cardiovascular Disease
Congestive Heart Failure
COPD
Diabetes
ESRD End Stage Renal Disease
Had a Stroke
Live in Long Term Care Facility
Recent/Pending Surgery
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Any Current PT Physical Therapy?

Optional - However helps me select a plan that fits your needs. Tell me about your health. In Last 3 years Any Hospital Stays? ER Visits? ANY RECENT CHANGES TO YOUR HEALTH? CARDIOVASCULAR? CONGESTIVE HEART FAILURE? COPD? ESRD?

Do you, your biological parents, or your biological siblings have HISTORY or EXPERIENCE with Cancer, Heart Attack, Stroke, or Cognitive Impairment/Dementia/Alzheimers?

Yes
No
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If Yes to Family History, Provide Details Age Diagnosed? Living? Deceased?

Have you and/or your family had any experience with home healthcare providers?

Yes
No
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Do You Have a Long Term Care Insurance Policy? If yes, provide Name. *

Do you have a Health Savings Acct./HSA? If yes, how much are you contributing? What is your balance?

Do you currently have Dental Insurance Now? Yes or No, If Yes, provide Dental Co. Name, Policy #, and How Long been in the Plan? Note this information is needed if you have dental and want me to recommend NEW Dental coverage. YOU MAY QUALIFY FOR A DISCOUNT OR TO WAIVE NEW WAITING PERIOD. *

Provide Co. Name/Policy#/How Long?

Seeking to REPLACE your current Dental? Vision? Hearing? D V H - Type Yes or No *

Using Hearing Aids? or a need for hearing aids? Yes or No *

Have you taken care of your final expenses? Does your family know if you want traditional burial or cremation?

Yes
No
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Do you have Life Insurance? If yes, do you want to increase or have Regina do a price check to replace what you have?

Do You Own A Business? *

Yes
No
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Employer or Business Name

Your Title, Business Address and Work Number

What Is Your Annual Household Income?

Under $20,000
$20,000 - $50,000
$50,001-$75,000
$75,001-$150,000
Over $150,000
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Do you have retirement benefit questions? Are you taking unnecessary risks with your retirement nest egg? If yes, may I schedule a separate meeting to discuss with Specialist?

Interested In A Future Meeting to Discuss Issues Medicare Does Not Cover? *

Yes
No
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***For Identification Purposes, provide Last four digits of SSN. *

For identification purposes Mother's Maiden Name *

Do you have an Authorized Representative? Please provide Name of Power of Attorney

Authorized Rep/POA Cell Phone - Required if applicable

REQUIRED IF SPEAKING TO an Authorized Rep or POA Address - Required if applicable

NOTES/COMMENTS/For HH Household DISCOUNTS; Spouse - Over age 60 for Sibling/Parent/Domestic Partner Discounts- Provide Name, Date of Birth and Email.

For those seeking Medicare help, you will be emailed AND texted a Scope of Appointment Link SOA (required by Medicare - Email will come from MedicareApp [email protected]), checking all boxes will allow Regina to talk to you about all topics. And the text will come from +1-201-299-6722. Complete as soon as possible. 48 hours have to pass before your meeting. You only need to complete one, the email or the text link. (CHECK JUNK/SPAM FOLDER), MEDICARE 101 VIDEO WILL BE EMAILED/TEXTED. PLEASE WATCH 1 HOUR EDUCATIONAL VIDEO BEFORE YOUR MEETING WITH REGINA. WRITE DOWN YOUR QUESTIONS. SHE WILL ANSWER THEM.

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All Things Insurance Benefits

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Form completed - Today's Date *