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Are you currently enrolled in Medicare Part B?

If you aren't sure of the actual date, please make an estimate.

Date Enrolled

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Date Effective
Are you currently covered by other health insurance?

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Who is your current health insurance provider?

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Spouse/Partner Supplemental Information

Are they currently enrolled in Medicare Part B?

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Date Enrolled

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Date Effective
Is your spouse/partner currently covered by other health insurance?

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Please Indicate thier OTHER plan type:

Who is their current health insurance provider?

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