New Client Intake & CNA

NEW CLIENT INTAKE FORM

First Name *

Last Name *

Goes By:

Date Of Birth *

Phone *

Email *

Address

Street Address

City

State

Postal Code

County

CLIENT NEEDS ANALYSIS

What are you hoping to accomplish today on our call?

* Employment & Social Security Questions are for T65

Employment Status:

Are you currently receiving Social Security benefits?

If no, have you already applied for Medicare Parts A & B?

Household Income:

$

* Now tell me a little bit about your current health insurance

What Kind of Insurance Do You Currently Have?

Is there anyone else on this insurance?

Current Insurance Carrier:

Plan Name/Plan Code:

Monthly Premium (Individual Only):

$

Deductible:

$

MOOP:

$

Specialist Co-pay:

$

PCP Co-pay:

$

* Make sure to asks these, it embeds and frame ancillary

Do you have any personal experience or family history with the "Big 3" (Cancer, Heart Attack, or Strokes)?

Do you have any personal experience or family history with home health care or skilled nursing?

Is having dental, vision, or hearing coverage important to you?

Do you have a reliable plan for protecting your finances against inflation and market changes?

Notes:

Recommendation:

SENSITIVE INFORMATION

Social Security Number

Medicare Number (MBI)

Part A Start Date

Part B Start Date

Extra Help (LIS) Level

Extra Help (LIS) Percentage

Medicaid Number

Medicaid Level