Please fill in your personal details below This section is for official use only *Select Agent's Name: —Please choose an option—Adriana MirandaAngelica Gerardo VejarCiria JuveraCourtney SnellCynthia Judith SchwartzDena WilliamsElsa EstradaEnnett MerlosErich MalschafskyJennise LopezJesus GarciaEliana MoraFrancisco EstevesLarissa Jeannette SwartzLucia VictoriaLuis Merlos RamirezLuis RamirezLuis RiveroCristina RamirezPaola FajardoRoberto BedollaYesenia GaleanaSabrina ManjarrezSherry UpshawStephen Horne MarshburnSylvana CarreteTracy GallihughWilliam SwartzRosaura CarmonaChujian LeiRoberto BedollaAlejandra AceroMarycruz MatiasKarem RodriguezOther Your name if you are submitting for another agent: Your Email if you are submitting for another agent: *Source Of Event: —Please choose an option—Office Walk-inSenior Housing EventsProvider ReferralCommunity EventReferralCampSales PresentationOther *Please select your office location—Please choose an option—SBHIS FresnoSBHIS Los AngelesSBHIS ModestoSBHIS OrangeSBHIS San Diego Bay BlvdSBHIS San Diego LstSBHIS San Diego VistaSBHIS San FranciscoSBHIS San JoseSBHIS StocktonOther *Please type the name of your office location *Please select your office walk-in type—Please choose an option—Customer ServicesMedicare ProspectOther *Please type the office walk-in type Please type the office walk-in referral (Only if apply) *Please select the lead source—Please choose an option—SD_MRC_ChulaVistaCenter_22021SD_SanYsidroHealthCenterSD_MRC_Headquartes_102020SD_MRC_Oceanside_062021Other *Please select the lead source—Please choose an option—SD_Member_ReferralSD_Pharmacy_ReferralSD_SocialSecurity_ReferralOther *Please type the name or member ID of the refering member *Please select the lead source—Please choose an option—SD_Dentist_ReferralSD_Optometry_ReferralSD_Doctor_ReferralLA_MosaicClinic_2021TX_Doctor_ReferralOther *Please select the location—Please choose an option—El CajonSan Diego King ChavezSan YsidroPrecision Park *Please select the location—Please choose an option—Naple DentistOther *Please type the name of the pharmacy *Please type the name of the Optometry *Do they have a vaccination appointment?:YesNo Their first dose date: Their second dose date: Which vaccination did they receive?Pfizer-BioNTechModernaJohnson & Johnson’s Janssen *Do they want to join the waitlist?:YesNo What dose do they want to wait for? 1st2ndboth Which vaccine do they prefer?Pfizer-BioNTechModernaJohnson & Johnson’s Janssen *Senior Housing Leadsource: —Please choose an option—IE_SeniorLiving_2021NC_SeniorLiving_2021NC_MothersDayFlowers_2021Other *Senior Housing Name: —Please choose an option—Valencia CommonsOther *Senior Housing Name: —Please choose an option—Plaza Towers and Annex ApartmentsLowell PlaceCasa Hernandez ApartmentsSteamboat Landing ApartmentsFranco Center ApartmentsOther *Type Senior Housing Name: *Type Senior Housing Leadsource: *Event Name: —Please choose an option—Bel-Air Swap-MeetAsparagus Festival 2021LA Community VaccinationsOther *Type Event Name: *Event Leadsource: —Please choose an option—Asparagus Festival 2021IE_CommunityEvents_2021LA_CommunityEvents_2021Other *Type Event Leadsource: *Sales Presentation Name: *Name of the provider: —Please choose an option—Carlos De CarvalhoEnrique Espinosa MelendezFrancisco MartinezLucy PollackRenato De La RosaRodney Hood *Name of the provider: —Please choose an option—Dr. Juan SilvaDr. Lisa MaDr. Kirstiema CowanDr. Leslie KleimDr. James MiyazakiDr. Hector Castillo * Required fields *First Name Middle Name/ Initial *Last Name *Phone Number Do you have a secondary phone number?YesNo *Secondary Phone Number Email *Address line 1 Address line 2 *City *State *Zip Code Would you like to add a second address?YesNo *Address line 1 Address line 2 *City *State *Zip Code *Do you have Medicare? Part APart BI don't know *Do you have Medi-Cal?YesNoI don't know Medi-Cal ID Number: Date of Birth *Language spoken:EnglishSpanishTagalogMandarin/ChineseVietnamese PCP Name: Medical Group: —Please choose an option—Physicians Medical Group of San JoseAllCare IPAOMNI IPA Medcore Medical GroupHill Physicians Medical GroupAsian American Medical GroupSCCIPA Medical GroupSante Community PhysiciansBrown and TolandQualCare IPANorthern California Physicians Network Medical Group: —Please choose an option—Mercy Physicians Medical GroupHPN-Regal Medical GroupHealthCare PartnersAltaMedScripps Physicians Medical GroupSharp Community Medical GroupVantage Medical GroupProspect Medical GroupCommunity Care IPAMultiCultural Medical GroupMultiCultural Medical GroupRiverside Physician NetworkPrimeCare Medical GroupSharp Rees Stealy Medical GroupXimed Health Excel IPAGreater Tri Cities IPASan Ysidro HealthGolden Physicians Medical GroupImperial County Physicians Medical Group: Health Plan name: Notes: *Please sign your full name in the box below *By submitting this form, you're agreeing to have a licensed SBHIS agent contact you by phone, postal mail or email to provide information about Medicare Advantage, Prescription Drug, and/or Medicare Supplement plans. We respect your privacy, and your information will not be shared without your permission. Your consent is voluntary and allows SBHIS to contact you via text messaging, phone, or automatic dialing for marketing purposes. You may change your preferences at anytime, and doing so will not affect your eligibility for Medicare Advantage Plan benefits and enrollment, coverage, or ability to get treatment. Data use charges and rates from your cellular carrier may apply.