Medicare Intake

This helps us compare plans before we meet, so your appointment is about answers instead of paperwork. It takes about 10 minutes. Have your Medicare card and your prescription bottles (or pharmacy printout) handy. Please fill out one form per person.

About You
Sex * Medicare Supplement rates are priced by this.
Do you live somewhere else part of the year?
Is someone helping you with this?
Your Medicare Status
Please don't type your Medicare number here. We only need the dates printed on your card. Keep the card handy for your appointment, and we'll take the number then if you decide to enroll.
Which best describes you? *
From your red, white, and blue card. Leave blank if you don't have it yet.
Leave blank if you haven't enrolled in Part B.
Are you (or your spouse) still working with health coverage through that job? *
Do you have Medicaid, or get Extra Help paying for prescriptions? * Just yes or no. Please don't enter a Medicaid number.
Do you have VA or TRICARE benefits?
Your Current Coverage
What coverage do you have now? * Check all that apply.
Why are you looking? Check all that apply.
Your Doctors and Hospitals

List the doctors you want to keep seeing, so we can check which plans have them in network.

Your Prescriptions

List every prescription you take, including inhalers, insulin, and injections. Copy them right off the bottle or your pharmacy printout. The exact strength matters, because it can change what a plan charges. Leave this blank if you don't take any.

Open to mail-order pharmacy?
What Matters Most to You
Which do you prefer?
How important is being able to see any doctor without a referral?
Extra benefits you'd use Check all that apply.
Do you travel outside South Carolina for more than a few weeks a year?
If You're Considering a Medicare Supplement

Outside your first enrollment window, Supplement companies can ask health questions. These help us know which companies will accept you. Skip this section if you're only interested in Medicare Advantage or a drug plan.

Have you used tobacco or nicotine in the past 12 months?
In the past 2 years, have you been diagnosed with or treated for any of these? Check all that apply.
Anything Else

We do not offer every plan available in your area. Currently we represent 6 organizations which offer 52 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.

Mauldin Insurance Group is not connected with or endorsed by the U.S. government or the federal Medicare program.