Client Intake Form
(Legal First, Middle, Last & “Preferred”)
Date of Birth
(Legal First, MI, Last Name)
Physical Address (NO P.O. BOX-Street # and Name, City, State, Zipcode, County)
Mailing Same as Physical
Social Security # (*Optional, some companies may require)
Home Phone #
Mobile Phone #
Preferred Method of Contact
How did you hear about us?
Current Coverage (Individual, Medicaid, Employer, Retirement, COBRA, Christian Health Ministries, Medicare, etc.)
Are you a Veteran?
If Veteran, recieving benefits?
Medicare ID# (if applicable) (NAEN-AEN-AANN)
Part A (_ _/01/_ _ _ _)
Part B (_ _/01/_ _ _ _)
Do you recieve extra help? (Low Income Subsidy, BigSky Rx, Medicaid, Prescription Assistance Program, etc)