Intake Form English

INTAKE FORM

This information will be used to find the most qualified plan that meets your needs and delivers the services you require for a healthy and active life. Be sure that you complete the form as thoroughly as possible.

First Name:

Last Name:

Address number and street name:

City:

State:

Zip:

Phone number

Type

Cell phone Home phone

E-mail:

Date of birth:

Medicare ID number:

Medi-Cal/MediCaid ID number (if applicable):

Medi-Cal/MediCaid State:

Medical Group assigned:

Primary Care Physician Name:

Primary Physician address:

Dental office Name:

Dental office address:

Please list all additional physicians that you are currently seeing:

Physician Name	Specialty (e.g., Cardiologist)

Do you have any of the following Chronic conditions?

1. Congestive Heart Failure

Yes No

2. Coronary Artery Disease

Yes No

3. Cardiac Arrhythmia

Yes No

4. Peripheral Vascular Disease

Yes No

5. Chronic Venous Thromboembolic Disorder

Yes No

6. Diabetes

Yes No

Please list any medications you are currently taking:

Name	Dose	Monthly Quantity

Do you have Power of Attorney (POA) or Appointment of Representation?

Yes No

First Name and Last Name:

Address, City, State, Zip Code:

Phone Number:

Relationship to the applicant:

Preferred Language:

English Spanish Other (please specify)

Please mark all items in the additional services section below according to your needs

Additional Services	Must have	Would like to have	Optional
Plan B Premium Rebate Allowance
Gym Membership
Diabetic Supplies
Dental/Vision
Hearing Aids Coverage
Over-The-Counter Allowance
Grocery Allowance
Air Purifier/Humidifier
Pet Services
Pest Control
Personal Emergency Response System (PERS)
In-Home Support Services
Transportation
Other

If you have any questions, please reach out to our services team at 1-877-784-5278 for further assistance.

This document is the property of Vikast Insurance Services and may not be copied, reproduced, or distributed without prior written consent.

If you have any questions, please reach out to our services team at 1-877-784-5278 for further assistance.

INTAKE FORM

Please list all additional physicians that you are currently seeing:

Please list any medications you are currently taking:

Please mark all items in the additional services section below according to your needs

Forms