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:

Working - Full Time
Working - Part Time
Retired/Retiring
Unemployed
Disabled
Other
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Are you currently receiving Social Security benefits?

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

Yes
No
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Household Income:

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

What Kind of Insurance Do You Currently Have?

Employer
Spouses Insurance
VA
Tricare
Marketplace/ACA
Medicare Supplement
Medicare Advantage
Original Medicare
Medicaid Only
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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

3
2
1
4
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Extra Help (LIS) Percentage

100%
75%
50%
25%
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Medicaid Number

Medicaid Level

FBDE
QMB+
SLMB+
QMB
SLMB
QI
QDWI
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