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Medicare Supplement Review
Health Questionnaire – Appointment Scheduled
Please provide the date of your scheduled appointment with HTA
(Required)
First Name (as on Medicare ID Card)
(Required)
Last Name
(Required)
Email Address
(Required)
Phone Number
(Required)
Has your Home Address (Primary Residence) changed in the last 12 months?
(Required)
Yes
No
Address
(Required)
City
(Required)
State
(Required)
Zip
(Required)
Would you like to review coverage for your spouse/partner?
(Required)
Yes
No
Spouse/Partner Information
First Name (as on Medicare ID Card)
(Required)
Last Name
(Required)
Email Address
(Required)
Medicare Supplement Plan
The best time to review your Medicare Supplement plan is typically around your policy renewal, when you receive your annual rate increase notice. If your rate has not changed since your last review, your options may be similar. Many clients find it helpful to compare rates every 3–5 years.
YOUR Medical Info
In most states, changing Medicare Supplement plans requires medical underwriting. Please answer the health questions below so we can better determine whether you may qualify to change plans and potentially lower your premium
Change Preference (check all that apply)
(Required)
I want to see if there is a lower premium for the same benefits i have now
I would be willing to consider lower benefits to save money
Current Plan
(Required)
Plan G
Plan F
Plan N
Plan High Deductible G (or F)
Medicare Advantage Plan
Other
Unsure
Current Premium
(Required)
Frequency
(Required)
Monthly
Quarterly
SemiAnnual
Annual
Have you recently received a rate increase notice?
(Required)
Yes
No
Date of Increase
(Required)
Premium after Increase
(Required)
Tobacco Use
(Required)
Yes
No
Congestive Heart Failure
(Required)
Yes
No
Heart Attack, Stroke or TIA
(Required)
Yes
No
Details on CHF, Heart Attack, Stroke or TIA including date of diagnosis, treatment, ongoing meds needed, degree of recovery, etc.
(Required)
Internal Cancer or Melanoma
(Required)
Yes
No
Atrial Fibrillation
(Required)
Yes
No
Diabetes
(Required)
Yes
No
Details on Cancer or A-Fib including date of diagnosis, treatment, ongoing meds needed, degree of recovery, etc.
(Required)
Diabetes with insulin use
(Required)
Yes
No
Diabetes with complications (Retinopathy, Neuropathy, Peripheral Vascular or Arterial Disease)
(Required)
Yes
No
Please provide any additional details about diabetes including how long you have had it, have your medications changed in the last 12 months, A1C levels, etc
(Required)
Kidney or Liver Disease
(Required)
Yes
No
Osteoporosis and have fractured a bone in last 5 years (regardless of if related to osteoporosis)
(Required)
Yes
No
Parkinson's Disease, Rheumatoid Arthritis or Multiple Sclerosis
(Required)
Yes
No
Details on Kidney, Liver, Osteoporosis, Parkinsons, Arthritis or MS including date of diagnosis, treatment, ongoing meds needed, degree of recovery, etc.
(Required)
Any physical, occupational or speech therapy- in past 6 months, current, or recommended?
(Required)
Yes
No
Any scheduled or recommended surgery or treatment in next 12 months?
(Required)
Yes
No
Details on PT, OT or any upcoming surgeries or treatment including reason for treatment, anticipated recovery time, etc
(Required)
SPOUSE/PARTNER'S Medical Info
In most states, changing Medicare Supplement plans requires medical underwriting. Please answer the health questions below so we can better determine whether you may qualify to change plans and potentially lower your premium
Change Preference (check all that apply)
(Required)
I want to see if there is a lower premium for the same benefits i have now
I would be willing to consider lower benefits to save money
Current Plan
(Required)
Plan G
Plan F
Plan N
Plan High Deductible G (or F)
Medicare Advantage Plan
Other
Unsure
Current Premium
(Required)
Frequency
(Required)
Monthly
Quarterly
SemiAnnual
Annual
Has your spouse/partner recently received a rate increase notice?
(Required)
Yes
No
Date of Increase
(Required)
Premium after Increase
(Required)
Tobacco Use
(Required)
Yes
No
Congestive Heart Failure
(Required)
Yes
No
Heart Attack, Stroke or TIA
(Required)
Yes
No
Details on CHF, Heart Attack, Stroke or TIA including date of diagnosis, treatment, ongoing meds needed, degree of recovery, etc.
(Required)
Internal Cancer or Melanoma
(Required)
Yes
No
Atrial Fibrillation
(Required)
Yes
No
Diabetes
(Required)
Yes
No
Details on Cancer or A-Fib including date of diagnosis, treatment, ongoing meds needed, degree of recovery, etc.
(Required)
Diabetes with insulin use
(Required)
Yes
No
Diabetes with complications (Retinopathy, Neuropathy, Peripheral Vascular or Arterial Disease)
(Required)
Yes
No
Please provide any additional details about diabetes including how long you have had it, have your medications changed in the last 12 months, A1C levels, etc
(Required)
Kidney or Liver Disease
(Required)
Yes
No
Osteoporosis and have fractured a bone in last 5 years (regardless of if related to osteoporosis)
(Required)
Yes
No
Parkinson's Disease, Rheumatoid Arthritis or Multiple Sclerosis
(Required)
Yes
No
Details on Kidney, Liver, Osteoporosis, Parkinsons, Arthritis or MS including date of diagnosis, treatment, ongoing meds needed, degree of recovery, etc.
(Required)
Any physical, occupational or speech therapy- in past 6 months, current, or recommended?
(Required)
Yes
No
Any scheduled or recommended surgery or treatment in next 12 months?
(Required)
Yes
No
Details on PT, OT or any upcoming surgeries or treatment including reason for treatment, anticipated recovery time, etc
(Required)
Other Coverages
Let us know if you’d like HTA to contact you about any of these coverages in the future:
Auto Insurance
Homeowners Insurance
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