- HTA Financial

Please complete your HIPAA Compliant Medicare Supplement Questionnaire! After you submit the questionnaire you will be redirected to a webpage to schedule an appointment if desired. Otherwise, we will email your options within the next few days.

Medicare Supplement Review Questionnaire

First Name (as on Medicare ID Card)(Required)

Last Name(Required)

Email Address(Required)

Phone Number(Required)

Ok to text with Plan information (if available)(Required)

Yes

Address(Required)

City(Required)

State(Required)

Zip(Required)

Would you like to also shop for a spouse/partner?(Required)

Yes

Spouse/Partner Information

First Name (as on Medicare ID Card)(Required)

Last Name(Required)

Email Address(Required)

Phone Number(Required)

Ok to text with Plan information (if available)(Required)

Yes

Medicare Supplement Plan

Shopping Medicare Supplement plans can be done any time of year, but typically requires medical underwriting (if you have been enrolled in Medicare longer than 6 months). The best time of year to shop your Supplement is when you receive your annual rate increase letter (typically 45 days before your annual renewal); however, you can change anytime throughout the year for the first of the following month effective date. If you have not had a rate increase since the last time we shopped your rate, the recommendation likely has not changed. People typically find it most effective to shop their Medicare Supplement rates every 3-5 years.

Would you like to shop a Medicare Supplement Plan?(Required)

Yes

Would you like to shop a Medicare Supplement Plan for your Spouse/Partner?(Required)

Yes

YOUR Medical Info

Please answer the questions and health information below so we may best determine if there is a savings opportunity available. Shopping Medicare Supplement plans requires medical underwriting (in most states). Please indicate if you have been diagnosed or treated for any of the following health conditions in the last 10 years.

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)

Current Premium(Required)

Frequency(Required)

Monthly

Quarterly

SemiAnnual

Annual

Have you recently received a rate increase notice?(Required)

Yes

Date of Increase(Required)

Premium after Increase(Required)

Tobacco Use(Required)

Yes

Congestive Heart Failure(Required)

Yes

Heart Attack, Stroke or TIA(Required)

Yes

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

Atrial Fibrillation(Required)

Yes

Diabetes(Required)

Yes

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

Diabetes with complications (Retinopathy, Neuropathy, Peripheral Vascular or Arterial Disease)(Required)

Yes

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

Osteoporosis and have fractured a bone in last 5 years (regardless of if related to osteoporosis)(Required)

Yes

Parkinson's Disease, Rheumatoid Arthritis or Multiple Sclerosis(Required)

Yes

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

Any scheduled or recommended surgery or treatment in next 12 months?(Required)

Yes

Details on PT, OT or any upcoming surgeries or treatment including reason for treatment, anticipated recovery time, etc(Required)

SPOUSE/PARTNER'S Medical Info