Dual Special Needs

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Medicare Dual Special Needs Plans

Get Over-The-Counter products, healthy food and more...

$105 a month to buy covered over-the-counter products and groceries
With $105 a month on one prepaid card, you can: • Buy OTC products, including pain relievers, vitamins, supplements, bandages, antacids, cough drops, allergy relief, toothpaste and more • Buy healthy foods, including fruits, vegetables, fish, meat, dairy, beans, bread, cereals, pasta and more • Shop at participating stores, including many national retailers and neighborhood stores, or order online with free home delivery options UnitedHealthcare Dual Complete® (HMO D-SNP) is a health plan for people who have both Medicaid and Medicare. It includes extra benefits to help you get care and services you may be missing today. All for a $0 plan premium.

Tell us about your needs...

Please take a moment to answer these optional questions the best you can to help us prepare for our Medicare Meeting. Each year the Medicare Plans can change as well as your personal needs. So please share these details below so we may better help you in the decision making process.

Since Medicare is based upon your location, what is your address?

* Indicates required field

Address *

Line 1

Line 2

City

State

Zip Code

Country

If Washington, which county? *

Skagit Snohomish King Other Washington County Outside of Washington State

Your Contact Information

Name *

First

Last

Email *

Phone Number *

Tell us about your needs...

List of Doctors (Name, Clinic and Phone) *

Medications List (Name, Dosage and Frequency) *

Are you on Medicare Now? *

Yes - Medicare Beneficiary Yes - Disability Medicare Beneficiary No - But I will be turning 65 soon No - But I will retire soon, currently on a work plan

If Yes, what Medicare Plan do you have? *

Medicare Advantage Medicare Supplement with Drug Coverage Medicaid NOT SURE

Are you a client of ours? *

Yes No

Are you happy with your current plan? *

Yes No Not Sure

Other questions, concerns or comments *

By submitting this form, you consent to a follow-up call by Birdseye Financial and their representatives. You acknowledge that we have requested your CONSENT TO CONTACT as per the rules of Medicare. If you are 65 years old or older, we will be required to ask you for an electronically signed SCOPE of appointment prior to our discussions of Medicare. This SCOPE simply allows us to discuss the different types of Medicare plans that you are interested in. By providing your contact information, you agree to allow a licensed sales person to contact you regarding Medicare options or to enroll in a plan. I understand that the person who will be discussing the plan options with me may e compensated based on my enrollment in a plan.

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