Medicare Client Needs Assessment

Completing this assessment helps us understand your coverage and planning preferences. If you are married, please have each spouse complete a separate form so we can consider your individual needs.

Questions? info@medicare-planning.com · (785) 979-9796

Protect your information: Please do not enter your Medicare ID, Social Security number, driver's license number, medical diagnoses, prescription names/dosages, or other sensitive health details here. We can arrange an appropriate secure intake process for those details. Do not send declaration pages or identity documents through ordinary email.

Personal information

First nameLast nameDo you have family nearby?Mailing address (street, city, state, ZIP)

Current Medicare coverage

Do you currently have Medicare Part A?When did your Part A coverage begin?Do you currently have Medicare Part B?When did your Part B coverage begin?What coverage do you currently have?Current insurance carrier and plan name (optional)Approximate monthly premium in dollars (optional)Why did you choose your current plan?

Planning for care and family needs

Has someone in your family used home care or nursing-home services?How were those services funded, if known?How would you plan to pay for future long-term care?Do you currently have life insurance?What purpose does your life insurance serve?Have you made arrangements for final expenses?Do you currently have a long-term care insurance policy?If yes, would you like to discuss a policy review?If no, would you like information about LTC coverage options?

Other financial and insurance questions (optional)

Are you satisfied with your current investment returns?Where are your investments primarily held?Do you have a 401(k), 403(b), or 457 plan you would like to discuss?Would you like information about home, auto, or boat insurance quotes?Would you like dental, vision, or hearing coverage information?

Prescription coverage preferences

Preferred pharmacy name (optional)Current Part D prescription plan (optional)Additional questions or topics you would like to discuss (do not include health details)

Contact information and permissionEmail address *Phone number *Where are you in your Medicare journey? I authorize Medicare Planning to contact me about this assessment. This does not subscribe me to marketing emails.

To review your exact prescriptions, health history, Medicare number, or other confidential information, please ask us about a secure intake method.

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