Welcome! You're taking the first important step towards a clear understanding of your Medicare options. Our goal is to make this process as smooth, stress-free and simplified as possible. This brief questionnaire is designed to gather key information and provide us with the essential details we need to prepare for your personalized Medicare planning. Let's begin.

Full Legal Name *

Phone *

Email *

Date of birth *

Address *

Street Address *

City *

State *

Country *

Postal code *

How did you find us? *

Please provide name of who referred you. If Financial Advisor, please also provide their company name. Thank you!

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If you are currently over the age of 65, do you already have Medicare Part A and/or Part B?

Are you comfortable texting? *

Are you comfortable emailing? *

When do you plan on taking Medicare? *

If you are unsure when you should plan on taking Medicare, review this for guidance.

What date and year do you plan to retire/take Medicare? (this can be a rough estimate) *

Current Health Coverage *

Monthly Premium for My Health Insurance *

The Yearly Deductible Is *

The Annual Out of Pocket Maximum Is *

Do you have Dependents on this plan? *

If you have a dependent, is he/she elgible for Medicare?

~.... Next you will be reviewing an income chart for Medicare Premiums Plan B.

My Potential Medicare Costs

Medicare Part A typically has no monthly premium if you or your spouse have paid taxes for 40 quarters (10 years). The standard Medicare Part B premium is $185 per month, though individuals with higher Modified Adjusted Gross Incomes (MAGI) may pay more.
Medicare uses a 2-year look-back period to determine if you are subject to an Income-Related Monthly Adjustment Amount (IRMAA) for Part B and Part D. For instance, in 2025, Medicare will evaluate your 2023 MAGI to assess whether additional premiums apply.

SOURCE: Center for Medicare and Medi-Caid Services

Based on the chart above, my Medicare Part B premium would be *

~.... Next you will be reviewing an income chart for Medicare Premiums Plan D.

The estimated national average for monthly drug plan premiums is $46.50 for 2025. As with Medicare Part B, higher-income earners will pay an additional Medicare Part D (IRMAA) surcharge. (See the table below to calculate your costs.)

Medicare 2025 Part D Premiums by Income

Based on the chart above, my Medicare Part D Premium would be *

What is your profession or profession prior to retirement? *

Are you still working? *

If you answered yes that you are still working, does your employer have 20 or more employees?

When it comes to technology which are you? *

When it comes to Medicare planning which type are you? *

Do It Yourself (DIY)- I like to do my own research and figure things out on my own

Do It with Me (DIWM)- I like to do a little research yet still want someone to guide me and help answer all my questions

Do It for Me- (DIFM)- I don’t like to do any research and prefer to give someone the info they need to help me select the best plan based on my needs and budget

What are your top questions or concerns regarding your transition to Medicare? *

Who is your Primary Care Physician? *

Have you had any hospitalizations in the past 5 years? *

Do you currently have an HMO or PPO? (Do you know the difference between the two?) *

Are you comfortable being part of a "fixed" network (HMO) of doctors or would you prefer to select your own doctors at any time of referral? *

Can you comfortably afford $300-$500 per month for your health insurance? *

Do you have a preferred hospital? *

Do you have any concerns regarding a pre-existing health condition or family health history? *

How important are extra benefits like; gym membership, transportation, over-the-counter items, hearing aids, tele-health, vision credit for lenses/frames, chiropractor, acupuncture? *

What is your preferred method of communication? *

Text

Phone

Thank you for completing our Medicare Discovery Questionnaire! Please continue by selecting submit.