• Name *
  First Last
• Home Phone # *
• Cell Phone #
• Ok to text you?
  Yes

  No
• Email *
• Residential Street Address
• City
• State
• Zip Code *
• 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
• What Pharmacy do
  you use for a refill?
  OR Mail order?
• What do you pay now for each refill? Additional Comments?
• 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