Medicare Questionnaire Short and Simple form to ensure we can get this covered for you if you do qualify. Medicare Form Step 1 of 2 50% Please Select All That Apply.* Do you have Medicare? Do you live in a rural area? Do you belong to a provider network such as an ACO? Would you like 1-on-1 assistance with Brain U Online? Name First Last Email This iframe contains the logic required to handle Ajax powered Gravity Forms.