Medicare referrals - McNamara If you are a human and are seeing this field, please leave it blank. Fields marked with an * are required Medicare A & B? Do you have Medicaid? Any history of Diabetes? Any history of Heart conditions? Any history of Circulatory disorders? First & Last Name * Date of Birth * Street Address City/State/Zip County * Phone * Medicare ID Part A Start Date Part B Start Date Name of Primary Doctor City/Office/Hospital of Doctor Additional Notes