Enrollment Form Lead Intake, Application, or Annual Review Form Agent Name* Troy Baccus Purpose of call* Lead Intake Application Annual Review Start Call Recording*If outbound call: Click "Record" on dial keypad on RingCentral app. If inbound call: Call is automatically recorded. Call Recorded Recording Skipped Explain reason recording skipped*Valid reasons include no MAPD/PDP discussion, face-to-face meeting, communicated via email, client self-enrollment, etc.Client Name* Client Information/NotesDOB, Zip Code, Phone number, Email address, Gender, Part A/B Eff dates, etc.Will PDP or MAPD be discussed with client? Yes No Scope of AppointmentThis Scope of Appointment documents that you agree to discuss Medicare Part D plans and/or Medicare Advantage plans with a licensed agent. Please note that the person who will discuss these Medicare plans is contracted by insurance companies and Medicare plans. They do not work directly for the Federal government. This individual may also be paid based on your enrollment in a plan. This agreement does NOT obligate you to enroll in a plan, affect your current enrollment, or enroll you in a Medicare plan. I wish to discuss the following types of products: Part D plans Medicare Advantage Plans If client agrees to SOA disclosure, input client initials. Has client been satisfied with their current plan(s), any notes on plan?This year there are some new optional supplemental riders available, is this something you'd be interested in discussing? Yes No Available riders to discuss Dental/Vision Insurance Final Expense - Lump Sum Life Insurance Cancer - Lump Sum Cancer Insurance Heart Attack and Stroke - Lump Sum Heart Attack/Stroke Insurance Home Care Plus Hospital Indemnity Recovery Care Sale(s) Description*List carrier, name of plan, proposed effective date, premium and any policy fee. If multiple sales (ie Medsup and PDP) include both entries.Enrolling in (select all that apply)* Medsup PDP Medicare Advantage Dental/Vision Other (include in Sale Description section) Applying in which state?* Alabama Arizona Arkansas California Colorado Florida Georgia Hawaii Idaho Illinois Maryland Michigan Minnesota Missouri Montana Nevada New Jersey New York North Carolina Oregon Pennsylvania South Carolina Tennessee Texas Virginia Washington Wisconsin Wyoming Other (confirm agency appointment in state) First Name*First name as it appears on Medicare card Middle InitialMiddle initial (if any) as it appears on Medicare card Last Name*Last name as it appears on Medicare card Birthdate*Date of Birth Month Day Year Gender* Male Female Phone*Phone numberEmail*Email address Address*Residence Street Address (no PO Box) UnitUnit or Apt # City*City of Residence County*County of Residence State*State of Residence Zip Code*Residence Zip Code Have a Preferred Mailing Address Different than Residence?* Yes No Mailing AddressPreferred Mailing Address Mailing UnitUnit or Apt # Mailing CityMailing Address City Mailing StateState of Mailing Address Mailing Zip CodeMailing Zip Code Did you run an Rx report?* Yes No Why was an Rx report not required?* Client confirmed no prescriptions Other (explain in Sales Description) Medsup Enrollment type* Initial Enrollment Period Guaranteed Issue Underwritten State-Specific Birthday Rule Reason for Medsup Guaranteed Issue*For example, lost coverage, moved, MAPD trial period, etc. Remind Client to provide GI ProofThis can include MAPD card for plan that is ending, termination letter from carrier, etc. Remind client that carrier will call with UW questionsMedsup Carrier*CarrierAetna (all Aetna companies)AllstateBlue Shield of CaliforniaBlue Cross Blue Shield MontanaCigna (all Cigna companies)Mutual of Omaha (all Mutual of Omaha companies)UnitedHealthcareOther (include in Sale Description)Medsup Plan Type*Plan GPlan NPlan FOther (specify in Sales Description section)Medsup Premium Amount (not including any HH discount)* Do you have a spouse?*Household discounts may apply Yes No Name of spouse* Spouse Date of Birth* Month Day Year Spouse Notes: particularly for use in HH discount determination Household Discount?* Yes No Collect spouse SSN for HH Discount Collect spouse SSN for HH Discount Collect spouse SSN for HH Discount Is there a Policy Fee?* Yes No Policy fee amount* Total Initial Premium with Policy Fee and HH Discount Total Initial Premium with Policy Fee Total Premium with Household Discount Tobacco in last 12 months?* Yes No Tobacco in last 12 months?* Yes No Tobacco in last 12 months?* Yes No Tobacco in last 12 months?* Yes No Tobacco Rates Will Apply. What is monthly Medsup premium for tobacco?* Tobacco Rates Will Apply. What is monthly Medsup premium for tobacco?* Tobacco Rates Will Apply. What is monthly Medsup premium for tobacco?* Tobacco Rates Will Apply. What is monthly Medsup premium for tobacco?* PDP Enrollment type* IEP - Initial Enrollment Period (new to Medicare) IEP2 - Aging in (Turning 65 and eligible for Medicare prior to age 65) AEP - Annual Enrollment Period (Oct 15 - Dec 7) SEP - Special Enrollment Period Reason For SEP* Loss EGHP Change in residence OEP - disenrolling from MAPD Institutionalized Invol Loss Creditable Cvg SEP 65 (joined MAPD T65 and leaving) Medigap trial period (dropped Medigap for MAPD) Remind client that LEP letter will be sent to them PDP Carrier*CarrierHumanaSilverscriptUnited HealthcareWellcarePDP Plan Name* PDP Premium*PDP Quoted Premium Amount MedAdv Enrollment type*What is the client's Election Period? IEP - Initial Enrollment Period (New to Medicare) IEP 2 - Aging In (turning 65 and eligible for Medicare prior to age 65) ICEP - Delayed Part B enrollment (s BEFORE Part B) AEP - Annual Enrollment Period (Oct 15- Dec 7) SEP - Special Enrollment Period OEP - MAPD Open Enrollment Period Switch (Jan 1-Mar 31) OEPI - Institutionalized Reason for MedAdv SEP* Change in Residence Loss of EGHP Invol Loss Creditable Cvg Contract termination Weather related emergency Medicare Advantage Carrier*CarrierAetnaBlue Shield of CaliforniaHumanaMontana Blue Cross Blue ShieldUnited HealthcareWellCareMAPD Plan Name* MAPD Plan ID Number* This number can be found via the quoting tool.MAPD Quoted Premium Amount* AARP Number* Are you a US citizen?* Yes No Will you be a US citizen at the time of your effective date?* Yes No If answer to this question is "No" then client is not eligible for a policy.State or country of birth* Medicare Number*Medicare Claim Number Part A Effective Date*Part A Effective Date MM slash DD slash YYYY Part B Effective Date*Part B Effective Date MM slash DD slash YYYY Social Security Number* Height and Weight List any YES answers to carrier underwriting questions*Current prescriptions as asked on carrier application*Currently residing in nursing home?* Yes No Currently on Medicaid?* Yes No Currently on Medicaid?* Yes No Currently on Medicaid?* Yes No Currently on Medi-Cal?* Yes No Medicaid Number* Medi-Cal Number* Have prescription drug coverage that will continue after enrolling?*Usually military-related, for example, Tricare or VA coverage. Yes No Name of other Rx Coverage* Currently have Medicare Advantage plan in force?* Yes No Name of Current MAPD Carrier* Currently have Medsup plan in force?* Yes No Name of current Medsup carrier* Current Medsup plan type*Plan F, Plan G, etc. If currently have MAPD/Medsup plan, when does coverage end? MM slash DD slash YYYY Is current Medsup plan being replaced? Yes No Is current MAPD plan being replaced? Yes No Reason for replacing Medsup/MAPD coverage Additional Benefits No change in benefits, but lower premiums Fewer benefits and lower premiums Does client currently have Dental Insurance?* Yes No Have other health insurance coverage in past 63 days?* Yes No Current health insurance company*Insurance carrier Type of current health insurance plan*Employer, HMO, major med, etc. When did current coverage start? MM slash DD slash YYYY When does current coverage end? MM slash DD slash YYYY Primary care physician* Primary care physician* PCP ID #Need to look up from carrier website Dental/Vision Insurance Carrier* Ameritas Delta Dental Dental/Vision Plan Name* Ameritas Enrollment Completed by Agent?* Yes, enrollment complete No, MLG will complete enrollment in-house Dental/Vision Quoted Premium* Medsup Requested Effective Date* MM slash DD slash YYYY Dental/Vision Insurance Requested Effective Date* MM slash DD slash YYYY Requested PDP Coverage Effective Date*PDP Effective Date MM slash DD slash YYYY MAPD Requested Effective Date* MM slash DD slash YYYY Medsup Payment Type*Payment OptionElectronic Funds Transfer (Monthly)Direct Bill (only if payment is Annual)Other (include in Comments section)Payment Type Comment PDP Payment Type*Payment OptionElectronic Funds Transfer (Monthly)Deduct from Social SecurityDirect Bill in Mail / Coupon BookMAPD Payment Type*Payment OptionElectronic Funds Transfer (Monthly)Deduct from Social SecurityDirect Bill in Mail / Coupon BookDental/Vision Payment Type*Direct Bill is not availablePayment OptionElectronic Funds Transfer (Monthly)Credit CardName of Bank* Routing Number* Checking Account Number* Credit Card Company*VisaMasterCardDiscoverCredit Card Number* Credit Card Expiration* CCV* Premium drafted upon approval?* Yes No - wait until effective date Have we sold them another health insurance plan in the last five years?* Yes No How Would Client Like to Provide Medsup Application Signatures?*Client will receive email from UHC with DocuSign remote signature option. Access Code is Residence Address Zip Code UHC E-App: Access Code is Zip Code How Would Client Like to Provide Medsup Application Signatures?*No client involvement required. MLG Direct Enroll How Would Client Like to Provide Medsup Application Signatures?*No client action required. Client will receive a link to their completed application for viewing purposes. They can access it with their date of birth and last 4 digits of SS# if they choose. Electronic Application How Would Client Like to Provide Medsup Application Signatures?*No client action required. Electronic Application How Would Client Like to Provide Medsup Application Signatures?*Client will receive email from Aetna and must provide last 6 of SSN to access application Electronic Application How Would Client Like to Provide Medsup Application Signatures?*Client will receive email from MOO with instructions to complete signature process Electronic Application How Would Client Like to Provide PDP Application Signatures?*No client involvement required MLG Direct Enrollment How Would Client Like to Provide PDP Application Signatures?*No client involvement required Wellcare Direct Enrollment How Would Client Like to Provide MADP Application Signatures?*No client involvement required MLG Direct Enrollment How Would Client Like to Provide MADP Application Signatures?*No client involvement required BCBS Electronic Application How Would Client Like to Provide MAPD Application Signatures?*Client will receive email from UHC with DocuSign remote signature option. Access Code is Residential Zip Code UHC Electronic App (Access Code is Zip Code) How Would Client Like to Provide MAPD Application Signatures?*No client involvement required Wellcare Direct Enroll Health Assessment for MAPD*Does client have any health conditions listed on Health Assessment survey? Yes No List health conditions for Health AssessmentClient Oral Signature*Read policy name, cost, and eff date to client. "Do I have your verbal consent to submit this application on your behalf?" I consent I do not consent Additional Comments Δ
