Medicare Fact Finder Client - Jeff Latall | Arch Brokerage | St. Louis, MO

Employee Benefit Plans
Medicare
Individual Coverage
Forms
About
Contact

Employee Benefit Plans
Medicare
Individual Coverage
Forms
About
Contact

Arch Brokerage Medicare Fact Finder - Jeff Latall

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Complete the medical fact finder to jump start your application process

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Client
Name
First Last
Email
Existing Arch Brokerage Customer?
- I am an existing Arch Brokerage customer
Date of Birth
Month
Day
Year
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Gender
- Male
- Female
County
Enter the County the City/Town is located in
Phone
Medicare Part A Effective Date
MM slash DD slash YYYY
Medicare Part B Effective Date
MM slash DD slash YYYY
Retirement Effective date
MM slash DD slash YYYY
Current plan coverage & monthly premium:
Smoker? (please enter Yes or No)*
How did you hear about us?
Do you have a medicare.gov account?
- Yes
- No
Medicare.gov Username:
Medicare.gov Password:
If you do not have a medicare.gov account, do you give Arch Brokerage permission to set one up on your behalf?
- Yes
- No
Please select below the type of product(s) you want the agent to discuss.
Stand-alone Medicare Prescription Drug Plans (Part D)
- Yes
- No
Medicare Advantage Plans (Part C) and Cost Plans
- Yes
- No
Dental/Vision/Hearing Products
- Yes
- No
Supplemental Health Products
- Yes
- No
Medicare Supplement (Medigap) Products
- Yes
- No

Client
PHYSICIANS
Primary Care
First Last
Specialist
First Last
Type of Specialist
Specialist 2
First Last
Type of Specialist
Specialist 3
First Last
Type of Specialist
Specialist 4
First Last
Type of Specialist
Hospital Preference
Prescription Drug(s) Currently Prescribed
Substitute Generics for Brand?
- Yes
- No
Preferred Pharmacy
Switch Pharmacies to Save?
- Yes
- No
If you are taking insulin, inhalers, creams, or lotions, please specify the number of pens, vials, inhalers, bottles, tubes, etc. taken per month or year. Please do not state "as needed" as we need an approximate quantity to provide an accurate review.
Form can accommodate up to 15 drugs and will automatically add additional drug lines if needed.
Please do not list any over-the-counter medications.
1. Prescribed Drug
Dosage (mg/ml)
Frequency (How often do you take this medication?)
Quantity
2. Prescribed Drug
Dosage (mg/ml)
Frequency (How often do you take this medication?)
Quantity
3. Prescribed Drug
Dosage (mg/ml)
Frequency (How often do you take this medication?)
Quantity
4. Prescribed Drug
Dosage (mg/ml)
Frequency (How often do you take this medication?)
Quantity
5. Prescribed Drug
Dosage (mg/ml)
Frequency (How often do you take this medication?)
Quantity
6. Prescribed Drug
Dosage (mg/ml)
Frequency (How often do you take this medication?)
Quantity
7. Prescribed Drug
Dosage (mg/ml)
Frequency (How often do you take this medication?)
Quantity
8. Prescribed Drug
Dosage (mg/ml)
Frequency (How often do you take this medication?)
Quantity
9. Prescribed Drug
Dosage (mg/ml)
Frequency (How often do you take this medication?)
Quantity
10. Prescribed Drug
Dosage (mg/ml)
Frequency (How often do you take this medication?)
Quantity
11. Prescribed Drug
Dosage (mg/ml)
Frequency (How often do you take this medication?)
Quantity
12. Prescribed Drug
Dosage (mg/ml)
Frequency (How often do you take this medication?)
Quantity
13. Prescribed Drug
Dosage (mg/ml)
Frequency (How often do you take this medication?)
Quantity
14. Prescribed Drug
Dosage (mg/ml)
Frequency (How often do you take this medication?)
Quantity
15. Prescribed Drug
Dosage (mg/ml)
Frequency (How often do you take this medication?)
Quantity
Additional Information
CAPTCHA
Phone
This field is for validation purposes and should be left unchanged.

PHONE

FAX

EMAIL

LOCATION

(314) 849-9292

[email protected]

8084 Watson Rd # 100,
St. Louis, MO 63119

Employee Benefit Plans Individual Coverage Medicare

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