Medicare referrals - Cassie If you are a human and are seeing this field, please leave it blank. Fields marked with an * are required Do you have Medicare A & B? Do you have Medicaid? Diabetes? Heart Conditions? Circulatory Disorders? First & Last Name * Street Address City State Zip County * Phone * Date of Birth * Marital Status * Married Single Widowed Separated Divorced Below LIS Limits? ($1500/$13k single or $2000/$27k married) Medicare Number Part A Start Date Part B Start Date Primary Doctor Name Primary Doctor Office or City Additional Notes