Medicare Questionnaire

BIRDSEYE FINANCIAL SERVICES (360) 722-7889

Home
About
Tools
Education
Planning
Products
Contact

WE SERVICE YOU...
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.

Medicare Questionnaire

Please take a moment to answer these optional questions the best you can to help us prepare for our Medicare Meeting. Plans can differ and change and we want to know what will impact you personally.

* Indicates required field

Address *

Line 1

Line 2

City

State

Zip Code

Country

YOUR INFORMATION

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 NOT SURE

Name *

First

Last

Email *

Phone Number *

List of Doctors (Name, Clinic and Phone) *

Medications List (Name, Dosage and Frequency) *

Are you a client of ours? *

Yes No

Are you happy with your current plan? *

Yes No Not Sure