Individual Healthcare Intake

Please complete the information below to the best of your ability. The information provided by you is helpful in determining which plan will best meet your needs in the upcoming plan year. As you are aware, this information is critical in allowing us to review options and find the best fit for you.

NAME*
First Last
DATE OF BIRTH*
MM slash DD slash YYYY
PHONE*
ZIP CODE*
COUNTY*
EMAIL*
ARE YOU TAKING ANY PRESCRIPTION MEDICATIONS?*
- Yes
- No
PLEASE LIST ANY CURRENT PRESCRIPTIONS*
Full Rx Name Brand or Generic? Dosage Frequency Form

Example: Lisinopril, generic, 20mg, 1x per day, capsule
DO YOU PREFER:*
- Local Pharmacy
- Mail Pharmacy
NAME OF YOUR PREFERRED LOCAL PHARMACY*
NAME OF YOUR SECONDARY PREFERRED LOCAL PHARMACY*
PRIMARY CARE PHYSICIAN:
Name Specialty Location Phone

Example: Dr. John Doe, Cardiology, Plantsville, 860-123-4567
ARE YOU CURRENTLY ENROLLED IN MEDICARE? (CHECK ALL THAT APPLY)
- MEDICARE PART A
- MEDICARE PART B
WHAT TYPE OF HEALTH COVERAGE DO YOU HAVE CURRENTLY?
NOTES: (ANYTHING YOU WANT OR NEED US TO KNOW TO HELP US REVIEW YOUR OPTIONS)
ELECTRONIC SIGNATURE
PLEASE TYPE YOUR FIRST AND LAST NAME
MEMBER SIGNATURE*
DATE*
MM slash DD slash YYYY
TERMS OF ACCEPTANCE and SIGNATURE I, the applicant for this Provider Drug Form, warrant the truthfulness of the information provided in this application.*
I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the Terms of Acceptance and I would like a Representative to contact me to review Medicare plan options.
If you have any questions regarding this form, please contact Lighthouse at 800.344.3531

Full Rx Name	Brand or Generic?	Dosage	Frequency	Form

Name	Specialty	Location	Phone

Individual Healthcare Intake

ELECTRONIC SIGNATURE

If you have any questions regarding this form, please contact Lighthouse at 800.344.3531