Please complete a separate form for each medicare beneficiary.  For example, if husband and wife in the same households complete a separate submission for each name.  If you are completing the form on behalf of a family member, please list the medicare beneficiary’s name and provide your information in the “additional information” box.

Your Name (please provide first AND last name)

Your Address

Email Address

Phone Number

List of Medications (please list name of drug, dosage, quantity – i.e Generic Lipitor, 10 MG, 1 x daily) If no current medications type “none”.

Preferred Pharmacy (list the pharmacy name you use to obtain your prescriptions. If you prefer mail order, please provide a pharmacy name in the event you would need to go to a pharmacy)

Do you ever use mail order?

Current Prescription Plan (please provide name of plan and premium if known – i.e. Humana – $7.00. If unsure, leave blank)

Is there anything else you would like us to know, or to take into consideration?

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