Medicare Questionnaire
Our goal is to service our clients at the highest level possible. In doing so, we touch bases with you every year. We check your doctors, medications and speak with you about your personal needs and how they may change from year to year. This information below will help us serve you better prior to our next conversation.

    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?
    Your Contact Information
    Tell us about your needs...
    Spouse Information (If Applies)
    Tell us about your needs...
    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. ​
Thank You for your submission...
IMPORTANT DATES FOR MEDICARE
Retiring from an Employer
When your turning age 65
Annual Changes to Medicare
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