CMF - Clayton

Strategy Session Questionnaire

Please provide us as much information as possible so we can do an accurate analysis. Your personal information will never be shared with anyone outside of our organization.

Name*

Date Of Birth *

Phone*

Home Address*

County*

Email Address

Medicare Number

Part A Effective Date

Part B Effective Date

Current Plan Name (if applicable)

Questionnaire

Answering these questions helps us identify a plan that meets your specific needs

I have end stage renal diseaseI receive state Medicaid benefitsI am a military veteran with VA benefitsI receive Extra Help with prescription medications

What Is Your Hospital Of Choice?*

Who Is Your Primary Care Physician?*

Name Any Specialists That You See*

List Your Medications*

Please provide the name of the medications, the dosage, and the quantity you take daily

Special Notes For Your Agent

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