Who is doing this intake?

Your name and where you met the member.

Your name (outreach rep)

Event or location

Member's name

As it appears on their Medicare card.

First name

Last name

A number where we can reach them.

Phone number

Helps us confirm Medicare eligibility.

Date of birth

Their ID number, plus a photo of the card.

Medicare ID

Tap to take or upload a photo

PNG, JPG, or PDF

document.pdf

This information is encrypted and stored securely. Only the care team can see it.

Choose all that apply.

Rides to appointments Food & groceries Medications & refills Understanding benefits Local resources & programs Something else

Read each one with the member, then check to agree.

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We've got their information ready for the care team to follow up.