COMPREHENSIVE MEDICARE NEEDS ANALYSIS FORM

The annual Medicare enrollment period begins October 15th through December 7th. I look forward to scheduling a phone conversation with you between that timeframe, and receiving this (optional) completed Comprehensive Needs Analysis Form in advance of our meeting. Thank you so much! ~ Lisa Dailey

COMPREHENSIVE MEDICARE NEEDS ANALYSIS FORM

The information you share in this form is confidential, secure/encrypted, and entirely optional.

1. Client Information

Full Name:

Date of Birth:

Mailing Address:

Phone:

Is it okay to text you at this phone number?

Yes

Email Address:

Alternative Email Address:

Preferred Method of Communication (Check all that apply):

Phone

Text

US Mail

Medicare Part A and Part B Effective Dates

2. Current Coverage Snapshot

Current Plan Type

Original Medicare Only (Parts A & B)

Medicare Advantage with Prescription Drug Plan (MAPD)

Medicare Advantage without Prescription Drug Plan (MA)

Medicare Supplemental (Medigap)

Standalone Prescription Drug Plan (PDP)

Current Plan Name, Insurance Carrier, Effective date

Current Monthly Premium

Current Satisfaction Rating (1 Lowest - 10 Highest)

3. Health & Medical Needs

Current PCP & Specialists

Note: Please indicate if they are currently in or out of network. If more space is needed, please add to 'Notes' section below.

Frequency of doctor visits

Do you have expected procedures, surgeries, or treatments in the near future?

Do you have any chronic conditions that affect your plan choice?

Are dental, vision, and/or hearing benefits important to you?

4. Prescription Drug Review

Current List of Prescriptions

Note: Please include name, dosage, frequency, formula eg. tablet, capsule, liquid. If more space is needed, please add to 'Notes' section below.

Preferred Pharmacy

Retail (location) or Mail-Order

Any Issues with Medication Costs, Access, or Coverage Gaps?

5. Lifestyle & Personal Priorities

Travel Habits

Out of state or international coverage needs

Do you have an interest in fitness/wellness programs?

Eg. SilverSneakers, One Pass, Specific Gym Membership

Do you have an interest in alternative care therapies?

Acupuncture, Chiropractic, Naturopathic

Comfort in using telehealth or virtual visits

6. Financial Considerations

Comfort level of premiums and out of pocket costs (eg. copays, deductibles, etc.)

Current eligibility for Extra Help/Low Income Subsidy (LIS) or Medicaid

7. Concerns & Preferences

What's working well with your current carrier or plan?

What's not working, or has been frustrating with your current carrier or plan?

Are you open to changing your doctors, hospital systems, or pharmacy?

Any concerns about surprise balances on your bills, or coverage denials?

8. Annual Renewal Discussion Points

Reviews of plan changes for upcoming year (premiums, benefits, drug formulary, network updates
New plan options to compare side by side
Prescription drug cost projections for the year ahead
Discussing supplemental or extra coverage such as dental, vision, and hearing needs
What's new in the industry
Confirming enrollment choice, steps for changes, and timelines
Address any questions you may have

9. What is most important to you about your Medicare coverage for the year ahead?

Comments:

10. What can I do as your insurance advisor to offer you the best service for the year ahead?

Comments:

Insurance carriers you're interested in discussing (Check all that apply):

Aetna

Devoted

Kaiser Permanente

Moda Health (Supplemental/Medigap Only)

PacificSource

Providence

Regence

Wellcare

Please list up to three dates you're available for our phone appointment:

Best time of day for our meeting:

Morning Afternoon

Notes:

Please add any additional comments here.

Today's Date:

Thank you for completing this Needs Analysis Form. I appreciate your time, effort, and participation. This comprehensive information will help me prepare for our annual renewal meeting and allow me to serve you in the best possible way. If you've offered time options for our meeting, I will respond to you as quickly as possible to schedule our phone call. Also, I will follow-up by sending you an electronic request to complete a Scope of Appointment form by either email or text .

Disclaimer: Any Medicare sales calls we exchange may be recorded for quality assurance or training purposes. Medicare Disclaimer: I do not offer every plan available in your area. Currently, I represent 7 organizations which offer up to a total of 53 products, depending on your area. Please contact Medicare.gov or 1-800-Medicare, or your local State Health Assistance Program (SHIP) to get information on all your options.

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COMPREHENSIVE MEDICARE NEEDS ANALYSIS FORM

The annual Medicare enrollment period begins October 15th through December 7th. I look forward to scheduling a phone conversation with you between that timeframe, and receiving this (optional) completed Comprehensive Needs Analysis Form in advance of our meeting. Thank you so much! ~ Lisa Dailey

COMPREHENSIVE MEDICARE NEEDS ANALYSIS FORM

The annual Medicare enrollment period begins October 15th through December 7th. I look forward to scheduling a phone conversation with you between that timeframe, and receiving this (optional) completed Comprehensive Needs Analysis Form in advance of our meeting. Thank you so much! ~ Lisa Dailey

Lisa Dailey Insurance