Medicare Prescription Drug Plan Information Form
Your Personal Information:
Title
Your Name:
First Name* M.I. Last Name*
Birth Date:*
Gender:*
Email Address:
optional
Home Phone Number:*

Permanent Residence :
Street Address Line 1*:
Street Address Line 2:
City*:
County*:
State*:

Zip Code*:


Mailing Address:   (only if different from your Permanent Residence Address)
Street Address Line 1:
Street Address Line 2:
City:
County:
State:

Zip Code:


Please Provide Your Medicare Insurance Information:
Please take out your Medicare Card to complete this section:

- Please fill in these blanks so they match your red, white and blue Medicare card.

You must have Medicare Part A or Part B (or both) to join a Medicare prescription drug plan.
 Medicare Claim Number  (If you do not wish to give this information, fill the boxes with zeros (0)
  - - -
 Is Entitled To: Effective Date:
 Hospital (Part A) * Required
 Medical (Part B)*

Please Answer the Following Questions to assist us in running the Medicare report. It will show your best options.
Some individuals may have other drug coverage, including other private insurance, TRICARE, Federal employee health care benefits, VA benefits, or State pharmaceutical assistance programs.

Will you have other prescription drug coverage?

List All Medications:
Name
MG / MCG etc.
Daily Dosage