Medicare Information | Family Matters Insurance Agency

Medicare Information

Medicare Information Form

Venue

Date

Time

Received Flyer or Mailer?

Took Business Card(s)

Took 2023/24 Plan Pamphlet

Took Enrollment Kit?

GTL Flyer

Tobacco Use

How Much?

Free Text

Receiving S.S. yet?

Height

Weight

SS#

Hospital Cost Indemnity Plans

Dental / Vision / Hearing Plans

Medicare Supplement Options

Prescription Drug Plans (Part D)

Medicare Advantage Plans (Part C)

Life Insurance Protection

My Medicare Card

My Medicare Card

MBI #

(Part A) date (HSA?)

(Part B) date (Grp?)

County

Travel outside USA?

Name

Date of Birth

Home Address

Phone(s)

Email(s)

Spouse

DOB

My Primary Doctor

My Specialist(s)

My Dentist

My Pharmacy

Club Member?

Govt. Programs

Medicaid KAN-CARE Tri-Care Work Retirement Plan COBRA S.E.P.

* How many Employees: (if Disabled for Medicare… and you/Spouse have HEALTH INSURANCE THRU WORK)

>20

20+

100+

MediGap MedSup Co

Monthly($)

Current Plan

SELECT

Prescription Drug Plan

Monthly ($)

Notes or Extra info promised? Spouse/S.O?

Spouse/S.O.DOB

Hours:

Mon - Sat: 7am - 7pm

Sun: Closed

Anytime, Any Day by Appointment

Feedback

2400 W Pawnee St, Suite 112, Wichita KS 67213

Todd@FamilyMattersInsurance.com

(316) 444-0855 | Fax : 316-281-4777