Page 1 - MEDICARE TEST
P. 1
Questionnaire for Friends
If you plan to enroll in Medicare in the near future
Please send us your completed questionnaire by e-mail or FAX
Your completed evaluation will be sent to you by e-mail.
E-mail: doverhealthcareplanning@gmail.com
Fax: (562) 498-7348
Your Name and Mailing Address (including home zip code):
____________________________________________
____________________________________________
____________________________________________
____________________________________________
The county you live in: ___________________________________
Your e-mail address: _________________________________________
A: Enrollment and eligibility questions
1. What is your date of birth? ______ ______ ______
Month Day Year
2. Are you already enrolled in Part A of Medicare? Yes No
3. When will you begin your Medicare (A+B) coverage? ______ ______ ______
Month Day Year
4. Are you currently receiving Social Security payments? Yes No
5. Are you currently making contributions to a Health Savings Account? Yes No
6. Please check the boxes that apply to you.
Neither I nor my spouse currently works for a company with 20 or more employees.
I will not have access to retiree health coverage to supplement Medicare.
(If you have employer retiree health coverage you may not need an evaluation
D o v e r H e al t hcar e P l anni ng, L L C Page 1
