Are you a current client? *

Yes

No

Name *

First Name

Last Name

Cell Phone *

(###)

###

####

Land Line

(###)

###

####

Date *

MM

DD

YYYY

Are you over 65?

If yes, please continue to fill out Section A

Yes

No

Are you under 65?

If yes, continue to Section B

Yes

No

Are you a new applicant to Medicare?

Yes

No

Do you have a Red/White/Blue Medicaid Card?

If so, please bring to your appointment

Yes

No

Are you going to continue working?

Yes

No

Are you in your employers insurance?

Yes

No

Do you take any prescription drugs?

If so, please bring a list and dosage of each RX to your consultation

Yes

No

Tobacco User?

Yes

No

Do you travel often?

Yes

No

Are you a Colorado Resident?

Yes

No

Do you have current insurance?

Yes

No

Do you have an existing account on the Colorado Exchange?

Yes

No

Do you have a broker of record?

If yes, please read the following For me to help you, you'll have to request me to be your Broker of record, please call Colorado Exchange prior to appointment, this will allow me to help you in every aspect of your Health Care needs. (Colorado Exchange 855- 752-6749)

Yes

No

Tabacco User

Yes

No