Northern Colorado Licensed Medicare Provider

Get Started

We look forward to helping you find the best plan! Please complete the form on this page. Please note if you leave the page before submitting the form, your progress will not be saved.

Intake Questionnaire

Hidden

Next Steps: Sync an Email Add-On

To get the most out of your form, we suggest that you sync this form with an email add-on. To learn more about your email add-on options, visit the following page (https://www.gravityforms.com/the-8-best-email-plugins-for-wordpress-in-2020/). Important: Delete this tip before you publish the form.

Medicare Pre-assessment

Completing this form is completely optional. Providing information give us feedback so we can learn more about what you are looking to get from your Medicare options. *The information supplied will not be shared with any 3rd party.

Your Name(Required)

First Last

Your Phone(Required)

Your Email Address(Required)

Your Address(Required)

Street Address Address Line 2 City State ZIP Code

Marital Status

How did you hear about Choice City Health?

Your Current Coverage

I am looking for coverage for:

Do you currently have health insurance?

My current coverage:

If you are still working, is your employer larger than 20 employees?

Are you currently covered by an HSA (Health Savings Account)?

Have you started Social Security Retirement?

Are you a United States Veteran?

Your Profile

How Familiar are you with your Medicare options?

I know exactly what I want

I have some questions

Unsure & just starting the process

Do you know the differences between Medicare Advantage and Medicare Supplement?

Yes

Somewhat

Would you prefer a plan with a low to zero monthly premium and a maximum out of pocket or to pay a premium (i.e. $125 - $200/month) and have low out of pocket medical expenses?

1 - lowest possible monthly premium

5 – lowest out of pocket medical

Do you have a primary care physician?

Are you more comfortable with having a insurance network that is local HMO and possibly lower co-pays vs National – PPO and higher out of pocket/co-pays

1 - lower co-pays

5 – larger network, higher cost

How would you feel about your insurance carrier requiring you to obtain prior authorization for certain services?

1 - it’s fine with me

5 – deal breaker

Your Comments/Questions