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ISUSA Medicare Supplement Prescreen Form

Please complete this form to help us assess your eligibility for a Medicare Supplement plan. Answer all questions honestly, as inaccurate information may affect your application. For assistance, contact us at (817) 756-1442 .

Medicare Supplement Prescreen Questionnaire

Personal Information

Name
Home Address

Health Questions (Answer YES or NO by checking the appropriate box)

If you answer YES to any question, please provide details of the event, how long ago it occurred, and whether it is still ongoing.
Are you currently hospitalized, in a nursing home, assisted living facility, bedridden, confined to a wheelchair, requiring motorized mobility aid, or have you had an amputation caused by disease?
Are you currently receiving occupational, speech, physical therapy, or home healthcare services?
Have you ever had or been diagnosed with Emphysema, Chronic Obstructive Pulmonary Disease(COPD), chronic pulmonary disorders, or used supplementary oxygen?
Have you ever had or been diagnosed with Parkinson’s Disease, Arthritis restricting mobility, SystemicLupus, Myasthenia Gravis, Multiple Sclerosis, Amyotrophic Lateral Sclerosis, Scleroderma, ChronicKidney Disease (stage 3-5), Chronic Hepatitis, Cirrhosis, or renal failure requiring dialysis?
Have you ever been diagnosed with Alzheimer’s Disease, Dementia, Muscular Dystrophy, or any cognitive disorder?
Have you ever been diagnosed with or treated for AIDS, AIDS Related Complex (ARC), or HIV infection?
Do you have diabetes or take medication to control blood sugar, and have you been diagnosed with or treated for peripheral vascular disease, peripheral artery disease, kidney failure, kidney disease, stroke, transient ischemic attack (TIA), congestive heart failure, or any heart disorder?
Do you have diabetes or take medication to control blood sugar, and do you take three (3) or more medications (oral or injections) to control it?
Do you have diabetes or take medication to control blood sugar, and do you take three (3) or more medications to control high blood pressure?
Have you ever been advised to take more than 50 units of insulin daily or required more than 50 units for diabetes?
Within the past 2 years, have you had or been treated for internal cancer (e.g., liver, breast, lung), malignant melanoma, lymphoma, leukemia, Hodgkin’s disease, alcoholism, drug abuse, or been advised to have joint replacement?
Within the past 2 years, have you had or been treated for heart attack, cardiac angioplasty, pacemaker implantation, bypass surgery, stent placement, vascular angioplasty, endarterectomy, stroke, or transient ischemic attack (TIA)?
Have you been advised to have surgery (including cataract or joint replacement), medical tests, infusions, or therapy that has not been performed?
Have you been hospitalized three (3) or more times in the last 2 years?
Within the past 10 years, have you had or been diagnosed with Chronic Obstructive Pulmonary Disease, Emphysema, Chronic Bronchitis, Renal Failure, Alzheimer’s Disease, Dementia, Cognitive
Within the past 5 years, excluding oral medications, have you been advised to have surgery,injections, infusions, brain/nerve stimulation, focused ultrasound, dialysis, oxygen therapy, or othertreatments for tremors, cataracts, ulcerative colitis, Crohn’s disease, macular degeneration, aneurysm,bariatric surgery, gallstones, heart valve disease, organ/tissue/bone marrow transplant, coronary arterydisease, hepatitis C, kidney disease, pulmonary disease (OSA on CPAP without oxygen is acceptable),or osteoporosis?
Household Discount (Do you live with someone age 50 or older for 12 months or longer?)
Privacy Notice: Information collected is for insurance assessment only. For our privacy policy, visit www.insurancesolutionsusa.com/privacy-policy.
This form is for prescreening purposes only and does not guarantee coverage or eligibility.

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