Medicare Survey Question Title * 1. First and Last name (legal name) OK Question Title * 2. Date of Birth Date Date OK Question Title * 3. Member ID OK Question Title * 4. Group Number OK Question Title * 5. Do you have Medicare Part B OR a Medicare Advantage Plan? Medicare Part B Medicare Advantage Plan Neither Other (please specify) OK Question Title * 6. Have you been diagnosed with any of the following? (Can choose multiple answers) Diabetes Renal Disease (Not currently on dialysis) Renal Disease (Currently on dialysis) Kidney Transplant within the last 36 months None of the above OK Question Title * 7. Do you have a secondary insurance? If yes, what is your secondary insurance? No Yes (Who is your Secondary Insurance? Please provide Member ID & Group Number) OK SUBMIT TO THE FUNCTIONAL RD