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Medicare Fact Finder – Client
Individual Fact Finder
Prescription Drug Fact Finder
Scope of Appointment
Arch Financial
About
Contact
Employee Benefit Plans
Employee Benefit Plans Overview
Group Health Plans
Life Benefits
Dental Benefits
Vision Benefits
Accidental Death
Long Term Care Insurance (LTC)
Disability Benefits
Medicare
Medicare Overview
Medicare Supplements
Medicare Advantage Plans
Prescription Drug Plan
Life Insurance
Annuities
Long Term Care Insurance (LTC)
Dental Benefits
Vision Benefits
Travel Policies
Educational Video Series
2025 Fall AEP
Individual Coverage
Individual Coverage Overview
Health Insurance
Life Insurance
Annuities
Long Term Care Insurance (LTC)
Dental Benefits
Vision Benefits
Travel Policies
Forms
Medicare Fact Finder – Client
Individual Fact Finder
Prescription Drug Fact Finder
Scope of Appointment
Arch Financial
About
Contact
Arch Brokerage Medicare Fact Finder - Julie Muhlhauser
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Step
1
of
2
50%
Complete the Medicare fact finder to jump start your application process
Your answers are secure and confidential.
Client
Name
First
Middle
Last
Email
Phone
Existing Arch Brokerage Customer?
I am an existing Arch Brokerage customer
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Date of Birth
Month
Day
Year
Gender
Male
Female
County
Spouse Name
Spouse Date of Birth
Month
Day
Year
Medicare ID
Retirement Effective date
MM slash DD slash YYYY
Medicare Part A Effective Date
MM slash DD slash YYYY
Medicare Part B 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
PHYSICIANS
Primary Care
First
Last
Address
Specialist
First
Last
Type of Specialist
Address
Specialist 2
First
Last
Type of Specialist
Address
Specialist 3
First
Last
Type of Specialist
Address
Specialist 4
First
Last
Type of Specialist
Address
Hospital Preference
Prescription Drug(s) Currently Prescribed
Substitute Generics for Brand?
Yes
No
Preferred Pharmacy
Switch Pharmacies to Save?
Yes
No
Please do not list any over-the-counter medications. Please do not state “as needed” as we need an approximate quantity to provide an accurate review.
The form can accommodate up to 15 drugs and will automatically add additional drug lines if needed
1. Prescribed Drug
Dosage
Quantity
Please Select...
1
2
3
4
5
6
7
8
9
10
Other (Please Specify in Additional Information)
Frequency (How often do you take this medication?)
Please Select...
daily
weekly
monthly
yearly
2. Prescribed Drug
Dosage
Quantity
Please Select...
1
2
3
4
5
6
7
8
9
10
Other (Please Specify in Additional Information)
Frequency (How often do you take this medication?)
Please Select...
daily
weekly
monthly
yearly
3. Prescribed Drug
Dosage
Quantity
Please Select...
1
2
3
4
5
6
7
8
9
10
Other (Please Specify in Additional Information)
Frequency (How often do you take this medication?)
Please Select...
daily
weekly
monthly
yearly
4. Prescribed Drug
Dosage
Quantity
Please Select...
1
2
3
4
5
6
7
8
9
10
Other (Please Specify in Additional Information)
Frequency (How often do you take this medication?)
Please Select...
daily
weekly
monthly
yearly
5. Prescribed Drug
Dosage
Quantity
Please Select...
1
2
3
4
5
6
7
8
9
10
Other (Please Specify in Additional Information)
Frequency (How often do you take this medication?)
Please Select...
daily
weekly
monthly
yearly
6. Prescribed Drug
Dosage
Quantity
Please Select...
1
2
3
4
5
6
7
8
9
10
Other (Please Specify in Additional Information)
Frequency (How often do you take this medication?)
Please Select...
daily
weekly
monthly
yearly
7. Prescribed Drug
Dosage
Quantity
Please Select...
1
2
3
4
5
6
7
8
9
10
Other (Please Specify in Additional Information)
Frequency (How often do you take this medication?)
Please Select...
daily
weekly
monthly
yearly
8. Prescribed Drug
Dosage
Quantity
Please Select...
1
2
3
4
5
6
7
8
9
10
Other (Please Specify in Additional Information)
Frequency (How often do you take this medication?)
Please Select...
daily
weekly
monthly
yearly
9. Prescribed Drug
Dosage
Quantity
Please Select...
1
2
3
4
5
6
7
8
9
10
Other (Please Specify in Additional Information)
Frequency (How often do you take this medication?)
Please Select...
daily
weekly
monthly
yearly
10. Prescribed Drug
Dosage
Quantity
Please Select...
1
2
3
4
5
6
7
8
9
10
Other (Please Specify in Additional Information)
Frequency (How often do you take this medication?)
Please Select...
daily
weekly
monthly
yearly
11. Prescribed Drug
Dosage
Quantity
Please Select...
1
2
3
4
5
6
7
8
9
10
Other (Please Specify in Additional Information)
Frequency (How often do you take this medication?)
Please Select...
daily
weekly
monthly
yearly
12. Prescribed Drug
Dosage
Quantity
Please Select...
1
2
3
4
5
6
7
8
9
10
Other (Please Specify in Additional Information)
Frequency (How often do you take this medication?)
Please Select...
daily
weekly
monthly
yearly
13. Prescribed Drug
Dosage
Quantity
Please Select...
1
2
3
4
5
6
7
8
9
10
Other (Please Specify in Additional Information)
Frequency (How often do you take this medication?)
Please Select...
daily
weekly
monthly
yearly
14. Prescribed Drug
Dosage
Quantity
Please Select...
1
2
3
4
5
6
7
8
9
10
Other (Please Specify in Additional Information)
Frequency (How often do you take this medication?)
Please Select...
daily
weekly
monthly
yearly
15. Prescribed Drug
Dosage
Quantity
Please Select...
1
2
3
4
5
6
7
8
9
10
Other (Please Specify in Additional Information)
Frequency (How often do you take this medication?)
Please Select...
daily
weekly
monthly
yearly
Additional Information
CAPTCHA
Phone
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