Medicare Prescription Form (One Per Person) This is a secure form going through a secure website. Please enable JavaScript in your browser to complete this form.Name *FirstLastStreet Address *City *State *Zip *Phone *Email *How did you hear about us?/Who may we thank for the referral? *Gender *Date of Birth *Medicare Number *Part A Date *Part B Date *Is your individual income over $85,000 *YesNoIs your joint income over $170,000 *YesNoDo you have end-stage renal disease? *YesNoAre you in a long term care facility? *YesNoAre you receiving extra help from Medicare? *YesNoAre you covered by Medicaid? *YesNoAre you on Social Security Disability? *YesNoIf we do change your drug plan, how would you like to pay for the premium? *ACHSocial SecurityBillWhat are your preferred Pharmacies? Please list two *Current Prescription Plan? *Medicare AdvantageStand Alone Prescription Drug PlanWhich Company *AAAP AetnaAgeWellAllwellBlue Cross Blue Shield Blue Medicare Bright Health CarePlus Centers Plan for Health Living CIGNA Clover Devoted HealthElderplan Elixir EmblemHealthEmpire Blue Cross Envision Express Scripts Fidelis CareFlorida Blue Freedom Healthfirst HealthSunHumanaLassoMetroPlusMMM of Florida Mutual of Omaha Other Prominence Silverscript Simply Healthcare Solis Health United Health CareWellcareSpecific Plan Name *Please list your CURRENT prescriptions, including NAME, DOSAGE, TIMES/DAY, GENERIC? and NOTESPrescription 1BrandGenericPrescription 2Prescription 2BrandGenericPrescription 3Prescription 3BrandGenericPrescription 4Prescription 4BrandGenericPrescription 5Prescription 5BrandGenericPrescription 6Prescription 6BrandGenericPrescription 7Prescription 7BrandGenericPrescription 8Prescription 8BrandGenericPrescription 9Prescription 9BrandGenericPrescription 10Prescription 10BrandGenericPrescription 11Prescription 11BrandGenericPrescription 12Prescription 12BrandGenericPrescription 13Prescription 13BrandGenericPrescription 14Prescription 14BrandGenericPrescription 15Prescription 15BrandGenericPrescription 16Prescription 16BrandGenericPrescription 17Prescription 17BrandGenericPrescription 18Prescription 18BrandGenericPrescription 19Prescription 19BrandGenericPrescription 20Prescription 20BrandGenericReasons for submitting this form: *New to Medicare (Turning 65)Annual Drug Plan ReviewUnhappy with Current Coverage (drug plan/supplement/MAPD)Leaving Work or Cobra CoverageBy returning this form, you are agreeing to our contacting you, and using this information to provide you with quotes as requested. We will not share your information without your permission. Click the button below for our Privacy Policy. *AgreeSubmit VIEW OUR PRIVACY POLICY
