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Relative Health checkup image

Answer these simple questions about your Medicare eligibility then click "Medicare Checkup", to get started.

Are you age 65 or older?

Yes No

Do you have parts A & B?

Yes No

Do you have Medicaid/AHCCCS benefits?

Yes No

Last Name*

First Name / Middle Initial

 

Street Address

City

State / Zip*

AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Daytime Phone

Evening Phone

Email Address*

Preferred Contact

How did you hear about us?

Television Radio Newspaper Outdoor Advertising Referral Other

Do you have permanent Kidney Failure?

Yes No

Who is your current Health Plan carrier?

What type of coverage do you have?

HMO PPO POS Supplement Don't Know Other

How long have you been with this carrier?

Less than 1 year Between 1-3 years Greater than 3 years

Do you have a plan that offers a prescription drug benefit?

Yes No