New Client Intake Form

- Please have your medical records ready before completing this form: Insurance, prescriptions, and doctor/physician information.

- All fields marked with an asterisk ( * ) indicates a required field.

- All information will be treated as confidential and used solely for Medicare enrollment purposes through our office.

- Questions? We are here to help! Call our office at 810-534-3008 to speak with an agent.

First Name: *
Middle Initial: *
Last Name: *
Street Address: *
City: *
State: *
Date of Birth: *
Gender:
Marital Status:
ZIP Code: *
County: *
Email Address *
Home Phone:
Cell Phone:
Work Phone:
Emergency Contact Name: *
Relationship: *
Emergency Contact Phone Number *
Spouse's Name:
Spouse's DOB:
Spouse's Smoking Status:
If you have any children under the age of 26, please list their names and Dates of Birth below:
Have You Applied For Medicare Parts A & B?: *
Medicare ID #:
Part A Effective Date:
Part B Effective Date:
Are You A Smoker?: *
Employment Status: *
# Of Employees At Company (if applicable):
Name Of Your Health Insurance Plan:
What Is Your Monthly Premium Cost?:
Is Current Health Insurance Through Your Employer?:
Are You Currently On Medicare?: *
Do You Have Medicare Advantage or Medigap Policy?:

Please List ALL Prescription Medications You Currently Take:
 

Medication Name

Generic (Y/N)

Dosage (mg, drops, etc)

Frequency Taken

What Pharmacy Do You Use?: *
Are Pharmacy Options Limited In Your Area?: *
Do You Use Coupons For Any Medication? *
Are You Interested In Mail Order Prescriptions?: *

Please List ALL Of Your Doctors / Physicians (Medical, Dental, Specialists):
 

Physician's Name

Address

Specialty

Are You Opposed To Switching Doctors?: *
Are You Opposed To Switching Pharmacies?: *

Please Answer The Following Questions To The Best Of Your Ability:
 

Do You Have Any Chronic Medical Conditions?: *
Do You Travel?: *
Do You Need Assistance With Your Premium Costs?: *
Do You Have Funds In Place To Cover Unexpected Medical Bills?: *
Is There Anyone Else In Your Household That Is Eligible For Medicare?: *
Do You Want More Information About Dental, Vision, & Hearing Coverage?: *
Please List Any Questions You Would Like Answered During Our Consultation:
How Did You Hear About Tyrone Carr & Associates?:
If Applicable, Please List The Name Of Your Referral Source:

SUBMIT

SCHEDULE A FREE CONSULTATION WITH TYRONE CARR & ASSOCIATES

Let's have a conversation today! Call us to speak with an associate or schedule an appointment online.

 



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10299 E. Grand River Ave. Suite K

Brighton, MI 48116

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