Pre-Medicare Basics Survey What is today’s date? * (MM/DD/YYYY) Enter your birthday * (MM/DD/YYYY) First First Last Last Email How would you rate your overall knowledge of Medicare? * Excellent Good Fair Poor How would you rate your understanding of what the various parts of Medicare cover? * Excellent Good Fair Poor How would you rate your understanding of the costs associated with Medicare enrollment? * Excellent Good Fair Poor How would you rate your knowledge of how to access resources to help with Medicare planning and questions? * Excellent Good Fair Poor How would you rate your confidence in choosing a Medicare plan that works for you? * Excellent Good Fair Poor We would like to follow up with you in 30-45 days after your participation in this program. * I approve a follow up contact. I do not approve a follow up contact. Remember that your approval helps us to ensure that our programs are of value to our community. If you are human, leave this field blank. Submit
