Client Information Form

If any required questions do not apply to you, please enter N/A. This is a secure encrypted HIPAA-compliant document.

First Name

Middle Initial

Last Name

Residential Address (if different from above)

Alternate Number

Email address

Birthday

(month/day/year)

Medicare ID # (no dashes)

Found on red/white/blue card. Mix of 9 letters & numbers

Part A Effective Date

Part B Effective Date

Are you a Veteran?

Yes No Spouse of a Veteran Prefer not to say

My current insurance plan is:

Medicare Advantage Plan (Part C) Medicare Prescription Drug Plan (Part D) Medicare Supplement Policy (Medigap) Through My Employer Unsure

Current Insurance Carrier & Plan

Premium Amount (if none enter 0)

Current Stand Alone Prescription Drug Plan (PDP)

Only for Medicare Supplement policy holders

Premium Amount (if none enter 0)

Please rate your experience with your current health/drug plan

1 (Low) 2 3 4 5 (High)

For the upcoming year, I'd like to:

KEEP my plan

CHANGE my plan/carrier

EXPLORE my options

Which carriers are you interested in exploring?

Aetna

Cigna

Blue Cross Blue Shield

United Health Care

Humana

Wellcare

Devoted

Gold Kidney

Other

Do you spend a significant amount of time out of state where In-Network benefits would be valuable? (e.g. you spend 4 months in Nebraska with family)

Yes No

Do you have stand alone dental coverage (outside of MAPD)?

Yes No

Preferred Contact Method

Home Phone

Cell Phone

Text

Preferred Contact Time

Morning

Afternoon

Evening

Any

Alternate Contact (or Power Of Attorney) Name & Relationship

Alternate Contact (or Power Of Attorney) Phone and/or Email

PLEASE NOTE:

If you selected 'Keep my Plan' above, the next section is highly recommended, but optional. Please scroll to the bottom to sign and 'Submit' if you chose to skip this next section.

If you are 'Changing plans' or 'Exploring options', please complete the next section for the most accurate plan comparison.

All information entered is secure, optional, and HIPAA compliant.

PHARMACY INFORMATION

Preferred Pharmacy

Alternate Pharmacy

Do you use a Mail Order Pharmacy?

Yes No Sometimes

PRESCRIPTION LIST (Click 'Add another prescription' for additional entries)

Add another prescription

Do you receive any government assistance for prescription and/or medical costs?

'Extra Help' with prescription costs

Low Income Subsidy (LIS) / AHCCCS

Veteran Affairs

Unsure

If applicable, LIS / AHCCCS #

Primary Care Provider (PCP)

Add alternate PCP

Specialists

Add another Specialist

Important Facilities

Preferred Hospital: name & city (eg: St Joseph's Hospital, Phoenix)

Any other important facilities (e.g. pain clinic)

Do you have any chronic or disabling conditions? Check all that apply (Optional)

None

Diabetes Type I

Diabetes Type II

CHF-congestive heart failure

CVD- cardo vascular disease

COPD

Kidney Disease

Cancer

Other (list below)

Have you had any major health changes in the last year? (Optional)

Do you have any other needs - e.g. physical therapy, durable medical equipment, etc.? (Optional)

Interested in exploring other services offered by DRC Insurance? (Check any)

Critical Care / Cancer Plans

Hospital Indemnity (pays hospital stays)

Final Expense Planning

Term Life Insurance

IMPORTANT: I authorize my broker/agent to utilize any protected health information (PHI) I have voluntarily provided for the purpose of advising me regarding my health plan/other product options. I agree to be contacted by phone/email/text unless I state otherwise. No information will be disclosed to any third party except as necessary for providing quotes. Any electronic storage, transmission, or material copy will be kept secure and protected.

I agree

Signature (Please type full name to acknowledge signing form)

Date

Your information will be encrypted.

Client Information Form

Darrell R Crum, Broker

P.O. Box 7591, Chandler, AZ 85246