Drug and Doctor Form

Please fill out the form below. This information helps us to quickly and efficiently determine coverage options and recommendations for you. Thank You.

Step 1 of 4

Name(Required)

Email Address(Required)

Phone(Required)

ZIP Code(Required)

Birthdate(Required)

Medicare ID Number

(This is found on your red, white, and blue Medicare Card. If you don't have this card, leave this field blank.)

Who invited you to fill this form out?(Required)

Are you open to having your prescriptions mailed to you, if it saves you additional money?(Required)

Yes

Do you have Medicaid OR do you receive any financial assistance in paying for medical or prescription costs?(Required)

Yes

What is your Preferred Pharmacy?(Required)

type "none" if not applicable

**Do NOT include Vitamins or Supplements unless prescribed by a physician

Prescription Medications: Please enter the drug name as found on your current prescription medicines.

Medication Name	Dosage (MG Amount)	Type	Times Per Day	Quantity	Actions

There are no Prescriptions.

Doctors & Providers: Please enter all of your current Doctors & Providers below.

*Do not include over-the-counter items unless prescribed by a physician

Doctor First Name	Doctor Last Name	City	Zip Code (best estimate)	Specialty	Actions

There are no Doctors.

Do you have any additional questions or comments we should be aware of? (optional)

Phone

This field is for validation purposes and should be left unchanged.

Currently we represent 8 organizations which offer 52 products in your area. Please contact Medicare.gov, 1 – 800 – MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all your options. | This is a proprietary website and is not associated, endorsed or authorized by the Social Security Administration, the Department of Health and Human Services or the Center for Medicare and Medicaid Services. This site contains decision-support content and information about Medicare, services related to Medicare and services for people with Medicare. If you would like to find more information about the Medicare program please visit the Official U.S. Government Site for People with Medicare located at medicare.gov.