Medicare Needs Analysis
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Jacob Campbell Insurance Agency

By completing and submitting this Medicare Needs Analysis, you authorize Jacob Campbell Insurance Agency (NPN 7478173) and its licensed agents or representatives to contact you at the phone number or email address you provide. This may include calls, emails, or other forms of communication regarding your Medicare plan options, quotes, or any other services related to Medicare. Any information you provide will remain confidential and will only be used for the purpose of providing you with answers to your questions about Medicare or your Medicare options.

You understand that this consent is not a condition of enrolling in any plan and that you may revoke your consent at any time by notifying us. You also acknowledge that you have provided accurate and truthful information to the best of your knowledge.


We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program to get information on all of your options. Service and product availability varies by state. Sales agents may be compensated based on a consumer’s enrollment in an insurance plan. No obligation to enroll. 


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Your Full Legal Name *
Date of Birth *
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Current Address *
County you live in *
Phone Number *
Email Address
Are you already enrolled in Medicare?
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If Yes, What is your Medicare Number and your Part A and Part B effective dates (These are found on your Medicare Red, White, and Blue card that you received from Social Security)
Are you turning 65 in the next 6 months or have you recently turned 65? (This helps with initial enrollment period timing)  
If you are employed, do you plan to continue working after age 65? If so, do you have employer-based health coverage?  
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Are you currently receiving Social Security benefits?  
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Do you have any employer or union-based health insurance (e.g., retiree benefits, COBRA)?  
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Do you have Medicaid?
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Do you have a chronic condition such as Diabetes or a Heart Condition?
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Do you currently have health insurance other than Medicare (e.g., employer-sponsored, private health insurance)?  
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If yes, what type of insurance do you have?  
List all your doctors including any specialists that you see. (This is optional, but will help determining the best plan that has your doctors in-network)
List all your regular prescriptions that you take on a regular basis as well as the dosage amount. (This is optional, but will help determine the best plan that covers your prescriptions at the best prices)
Which Hospital would you prefer to go to if you ever needed to go? (This is optional, but will help in determining the best plan that has your preferred hospital in-network)
Do you expect any significant medical needs in the coming year (e.g., elective surgeries, treatments, or new prescriptions)?  
What is your monthly budget for health insurance premiums, deductibles, and out-of-pocket costs?  
Are you eligible for Medicare Savings Programs (MSPs) or Extra Help for prescription drug costs?  
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Do you travel often or live part-time in another state or country? This might impact your choice of plan, especially with Medicare Advantage, which can have network restrictions.  
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Do you have any concerns or confusion about Medicare that you would like clarified?  
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