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

Employee Benefit Plans
Medicare
Individual Coverage
Forms
About
Contact

Employee Benefit Plans
Medicare
Individual Coverage
Forms
About
Contact

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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

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Comments

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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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