• Please type into this form your prescription, and physician information so we can research Medicare Insurance Plans available for you that you feel would be a good fit for your needs and preferences in the new year.

  • Prescription Spelling Dosage (mg, ml,etc) QTY in refill (#tabs) Frequency? (1xmth etc) Is it Generic? Purchased With Coupon or from Canada etc?
    Medication 1
    Medication 2
    Medication 3
    Medication 4
    Medication 5
    Medication 6
    Medication 7
    Medication 8
    Medication 9
    Medication 10
    Medication 11
    Medication 12
    Medication 13
    Medication 14
    Medication 15
  • Doctors: List your Doctors in the chart below and rate them with how important it is for you to be able to see the same doctors in the next year.
    Note doctors can leave a network at any time in the year if you have an HMO Plan. You can usually only change networks in January of each year.

  • First Name Last Name Type of Doctor City Ave # of visits per year Importance of keeping the doctor (H,M,L)
    Provider 1
    Provider 2
    Provider 3
    Provider 4
    Provider 5
    Provider 6
    Provider 7