Client Intake Form — EIG Senior Care

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Personal Information

Basic details so we can match you with the right plan

First Name *

Last Name *

Date of Birth *

Mobile Phone *

Email Address

Street Address

City

State

ZIP Code

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Doctors & Specialists

We'll confirm your doctors are in-network with your new plan

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Current Medications

We'll make sure your prescriptions are covered

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Care Coordination

Upcoming appointments & current care providers

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We coordinate care and make sure all your doctors are updated with your Member ID before appointments. You're never alone in this process.

Do you have upcoming office or doctor visits?

✅ Yes

No

When is your appointment?

Do you have upcoming surgeries?

✅ Yes

No

When is your surgery?

Do you have upcoming blood work, MRI, or PET scan?

✅ Yes

No

When is your appointment?

Do you have a current home healthcare provider that visits you?

✅ Yes

No

Provider Name

Are you in a facility care (nursing home, assisted living)?

✅ Yes

No

Facility Name

Do you need dental coverage?

✅ Yes

No

Dentist Name (if you have one)

Do you have an optometrist (eye doctor)?

✅ Yes

No

Optometrist Name

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Scope of Appointment

CMS-required authorization — Plan Year 2025

CMS Compliance Notice

The Centers for Medicare & Medicaid Services (CMS) requires agents to document the scope of an appointment prior to any meeting with a Medicare beneficiary to discuss Medicare Advantage Plans (Part C), Medicare Prescription Drug Plans (Part D), Medicare Supplement (Medigap), and other Medicare-related products. This form fulfills that requirement. Your information is kept confidential and used solely for Medicare enrollment purposes.

Beneficiary Name

Date of Birth

Products to be discussed * (check all that apply)

Stand-alone Medicare Prescription Drug Plans (Part D) Medicare Advantage Plans (Part C) and Cost Plans Dental / Vision / Hearing Products Medicare Supplement (Medigap) Plans Medicare Medical Savings Account (MSA) Plans Hospital Indemnity Plans

Method of Contact *

Agent Name

Agent Phone

Date

Beneficiary Signature *

Sign with your finger (mobile) or mouse (desktop)

✓ Signature captured

Beneficiary Statement

By signing above, I confirm that I requested information on the Medicare products listed above. I understand that a licensed insurance agent may contact me to review my Medicare coverage options. I am not obligated to enroll in any plan. This Scope of Appointment does not obligate me to enroll in any plan.

Client Intake & Scope of Appointment

You're All Set!