Medicare Health Plans Quote Request

Medicare

Medicare Supplement Health Plans Quote Request

Part I - Applicant Information
* First Name
* Last Name
Birth Date
Medicare #
Age
Sex
Height
Weight
Have you used tobacco within the last 12 months?	Yes No
Applicant Address
Street Address
City
State
Zip Code
Phone Number
Alternate Telephone
* Email Address
Part II - Medical & General questions - Please give details to "yes". Include insured or spouse name.
A. Do you have a (or pending applications for) Medicare Supplement policy or certificate in force?	Yes No
If yes, please describe
2. If so, do you intend to replace your current Medicare Supplement policy with this policy?	Yes No
If yes, please describe
B. Do you have any other health insurance coverage that provides Medicare benefits?	Yes No
If so, with which company?
What kind of policy?
C. Are you covered for medical assistance through the state Medicaid program:
1. As a Specified Low-Income Medicare Beneficiary (SLMB)	Yes No
2. As a Qualified Medicare Beneficiary (QMB)	Yes No
3. For other Medicaid medical benefits?	Yes No
D. Are you covered or will you be covered under:
Medicare Part A (Hospitalization)	Yes No
Effective Date Insured:
Effective Date Spouse:
Medicare Part B (Medical Expenses)	Yes No
Effective Date Insured:
Effective Date Spouse:
Health Questions (Answer for all Insureds)
Within the past two (2) years for (a) through (e) have you had, or had a medical diagnosis of:
The below questions are not required of applicants applying for this coverage within 6 months of obtaining Medicare Part B, or under guaranteed issue status.
a. Cirrhosis; Hemophilia; Multiple Sclerosis; Leukemia; Amputations due to Diabetes?	Yes No
b. Renal Dialysis; Kidney Dialysis; X-Ray Therapy; Radium or Chemotherapy; Degenerative (Crippling) Arthritis; Internal Cancer; Stroke?	Yes No
c. Emphysema (under treatment); Hodgkins Disease; Disease or Disorder of Lungs or Respiratory Syustem which requires the outside assistance of a Mechanical Breathing Device?	Yes No
d. Heart attack; angina; transient ischemic attack (TIA); heart failure; heart surgery; angioplasty or coronary by-pass surgery?	Yes No
e. Parkinson's disease; Alzheimer's disease; senile dementia; organic brain disease or other senility disorders?	Yes No
2. Are you an insulin dependent diabetic taking more than 50 units per day?	Yes No
3. Have you been confined to a nursing home or a wheelchair within the past two years or has such care been medically advised?	Yes No
4. Are you currently hospitalized, or receiving Medicare approved home health care; or have you been hospitalized or received Medicare approved home health care three or more times in the past two years?	Yes No
5. Within the past year have you been medically advised to have surgery but not had such surgery?	Yes No
6. Within the past 5 years, have you been medically diagnosed by a member of the medical profession as having any disease or disorder of the immune system, AIDS Related Complex (ARC), or have you tested positive for the HIV infection?	Yes No
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* Required Fields

Balanced Healthcare Solutions, Inc. Local: 678-842-0335 Fax: 678-842-0339

Medicare

Medicare Supplement Health Plans Quote Request

Part I - Applicant Information

Applicant Address

Part II - Medical & General questions - Please give details to "yes". Include insured or spouse name.

C. Are you covered for medical assistance through the state Medicaid program:

D. Are you covered or will you be covered under:

Health Questions (Answer for all Insureds)

Within the past two (2) years for (a) through (e) have you had, or had a medical diagnosis of:

The below questions are not required of applicants applying for this coverage within 6 months of obtaining Medicare Part B, or under guaranteed issue status.

Balanced Healthcare Solutions, Inc.

Local: 678-842-0335
Fax: 678-842-0339