HS Consulting Group, Inc.
GoldMine Import Template 1
Name *
E-mail Address *
Work Phone #
Home Phone #
Cell Phone #
Address *
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City *
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Zip Code *

How did you hear about us? *

Notes/Concerns/Comments
Gender
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Birthdate
Medicare Number (no dashes)
Part A Eff. Date
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Current Medicare Plan (if any)
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