Pre-Qualification
Supplement Review

Medicare Supplements require ‘Underwriting’ in order to qualify for a new plan. You may have Guaranteed Issue if you are new to Medicare, losing group or retiree health coverage, or recently moved to a new state. Please provide the following information to get started.
 

Name
MM slash DD slash YYYY

Qualifying Questions - Please Answer To The Best Of Your Knowledge.

Have You Used Tobacco In Any Form, Electronic Cigarettes, Or Other Nicotine Products In The Past 24 Months?

Section 1. Within The Past 5 Years, Have You:

A. Had, Been Treated For, Or Diagnosed With Diabetes That Required Insulin, Required Three Or More Medications For Control, Or Had Complications?
B. Had, Been Treated For, Or Advised To Have A Bone Marrow Or Organ Transplant?
C. Had, Been Treated For, Or Diagnosed By A Member Of The Medical Profession With Acquired Immune Deficiency Syndrome (Aids) Or Aids-related Complex (Arc), Or Tested Positive For Human Immunodeficiency Virus (HIV)? (Disclose Only FDA-licensed Test Results And Not Anonymous Counseling & Testing Site Or Home Test Kit Results)

Section 2. Within The Past 24 Months Have You:

A. Had, Been Treated For, Or Diagnosed With Internal Cancer, Leukemia, Melanoma, Hodgkin’s Disease, Myeloma, Or Lymphoma?
B. Had, Been Treated For, Or Diagnosed With Amyotrophic Lateral Sclerosis (Als), Parkinson’s Disease, Or Multiple Or Lateral Sclerosis?
C. Had, Been Treated For, Or Diagnosed With Cirrhosis Of The Liver, Hepatitis B Or C, Chronic Renal/Kidney Failure, Or Had Dialysis?
D. Had, Been Treated For, Or Diagnosed As Having Had A Stroke Or Transient Ischemic Attack (TIA)?
E. Had, Been Treated For, Or Diagnosed With Peripheral Vascular Disease (Poor Circulation In Your Extremities), Had Angioplasty, Stent Placement Of Any Vessel, Bypass Surgery, Heart Attack, Heart Surgery, Or Congestive Heart Failure?
F. Had, Been Treated For, Or Diagnosed With Emphysema, Chronic Obstructive Pulmonary Disease (COPD), Or Other Chronic Pulmonary Disease?
H. Had Any Fractures Due To Osteoporosis Or Amputation Due To Disease?
I. Been Or Are You Now Bedridden Or Permanently Confined To A Wheelchair?
J. Had, Been Treated For, Or Diagnosed With Schizophrenia Or Bipolar Disease?
K. Been Confined To A Hospital For A Mental Or Nervous Condition?
L. Been Treated For Abuse Of Or Diagnosed With Addiction To Alcohol, Drugs, Or Opioids?

Section 3. At Any Time:

A. Do You Have Or Have You Been Told By A Medical Professional That You Have Alzheimer’s Disease, Dementia, Organic Brain Disorder, Or A Cognitive Disorder?
B. Are You Currently Using Oxygen?

Section 4. Please Answer The Following:

A. Do You Require Assistance Or Supervision To Perform Any Of The Following Activities Of Daily Living: Dressing, Eating, Bathing, Toileting (Including Use Of A Catheter), Or Walking (Including Use Of A Cane, Walker, Motorized Scooter/mobility Aid, Or Wheelchair)?
B. Has A Member Of The Medical Profession Recommended That You Have Medical Tests, Treatment, Therapy, Or Surgery, Including Cataract Surgery Or Joint Replacement, That Has Not Yet Been Performed?
C. Have You Been Hospitalized Within The Last 60 Days? Has A Member Of The Medical Profession Recommended That You Be Hospitalized, Confined To A Nursing Facility Or Assisted Living Facility, Or Received Home Health Care Within The Last 60 Days? Have You Been Hospitalized Or In The Emergency Room Three Or More Times Within The Past 24 Months?
D. Have You Had A Seizure Within The Past 24 Months?

Have You Taken Any Medication In The Last 12 Months, Including Injections Or Infusions? If Yes, Please Provide Details Below:

Please List Medication Name, Dosage, Diagnosis, And Start Date
MM slash DD slash YYYY
Have You Seen Any Specialists In The Last 24 Months?
Please list name, specialty and date of last visit for each.