About three months before your entitlement to Medicare, you are mailed the Initial Enrollment Questionnaire (IEQ). The IEQ asks whether you have other insurance that pays before Medicare. To ensure correct payment of your Medicare claims, it is important to complete and return the IEQ timely. The questionnaire takes only 5 minutes to complete.

Si usted desea recibir el IEQ en espanol, por favor llame al COB Contractor al telefono 1-800-999-1118 or TTY/TDD 1-800-318-8782 (toll-free).

Click on a link below to see a sample IEQ that applies to you. This questionnaire is not available in a downloadable format.

Contact the Coordination of Benefits (COB) Contractor's Customer Service Department toll-free at 1-800-999-1118 or TTY/TDD: 1-800-318-8782 for the hearing and speech impaired with any questions you have. Representatives are available to assist you Monday through Friday, from 8:00 a.m. to 8:00 p.m., Eastern Time, except holidays.

Downloads
English-Medicare Questionnaire for Beneficiaries 65 or Over, Page 1 (PDF, 524 KB) English-Medicare Questionnaire for Disabled Beneficiaries, Page 1 (PDF, 942) English-Medicare Questionnaire for Beneficiaries With End-Stage Renal Disease (PDF, 943 KB) English-Medicare Questionnaire for Beneficiaries With Childhood Disabilities (PDF, 1226 KB) English-Medicare Questionnaire for Disabled Widow Or Widower (PDF, 1021 KB) Spanish-Medicare Questionnaire for Beneficiaries 65 or Over (PDF, 1222 KB) Spanish-Medicare Questionnaire for Disabled Beneficiaries (PDF, 1053 KB) Spanish-Medicare Questionnaire for Beneficiaries With End-Stage Renal Disease (PDF, 10494 KB) Spanish-Medicare Questionnaire for Beneficiaries With Childhood Disabilities (PDF, 1427 KB) Spanish-Medicare Questionnaire for Disabled Widow Or Widower (PDF, 1141 KB)
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Page Last Modified: 12/14/2005 12:00:00 AM
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