Medicare Part D Evaluation Form

1

Name* This field is required.

First Name

Last Name

2

Date of Birth* This field is required.

Date

3

Email* This field is required.

example@example.com

Confirm Email

4

Phone Number* This field is required.

Please enter a valid phone number.

5

What plan did you have in 2022? (be as specific as possible)Aetna PDP, SilverScript Choice...etc,..

6

Please list all of your everyday or frequently filled prescriptions. Please include anything you would fill more than 2 times in a year.This should include all blood pressure, asthma, diabetes, etc...medications. Please DO NOT include time pain medications or antibiotics unless you take them prophylactically.

7

How do you want to be provided this document?

I will pick it up at the pharmacy in 3-4 days.

I would like it to be emailed to me for review (at the email provided earlier)

8

SignatureI agree to have my health information contained in this form be included in an email if I selected that in previous question. I understand that this is only a projection of my potential costs and that Vashon Pharmacy is not liable for any changes to plan costs, formularies or changes in healthcare not provided specifically within this form. I understand that Vashon Pharmacy is only providing information regarding my prescription drugs and not considering my medical conditions and/or insurance in any way in this equation. I agree to hold Vashon Pharmacy, its employees and affiliates harmless in any and all matters related to my selection of a Medicare Prescription Drug Plan.

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