2024 Prescription Plan Information

Name*

First NameLast Name

Date of Birth*

Date

Do you use any Tobacco products (or have used them in the last 12 months)?*

YesNo

Preferred Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Is the phone number above a cell phone or landline? (Note that we do not share this information with others - this is for us to contact you correctly)*

Cell PhoneLandline

Do you have a different phone number? If so, list below.

Please enter a valid phone number.Format: (000) 000-0000.

Is this phone number above a cell phone or landline?

Cell PhoneLandline

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

What COUNTY do you live in? (Example: Ozaukee, Washington, Milwaukee, etc)

County

Are you a Veteran?

If you are a Veteran, do you use the VA for your prescriptions?

My Pharmacy Preferences (Please put in multiple choices unless you will ONLY go to one pharmacy even if it costs more).*

Mail Order and SeniorCare Rx Options*

Please enter ALL your prescriptions here. Use your bottle/container for reference. Include ALL details (XR, ER, etc.), pens, 2 inhalers per year, etc.) If you are on INSULIN, please just tell the number of boxes of pens or vials you need per month. DO NOT give us units of insulin. Be as specific as possible - seemingly small differences can make a huge price difference. Put details in the box provided later in the form if you have questions.

Do you currently use GoodRx or SingleCare for any of your prescriptions. If so, please list them below.

Who is your current Primary Care Physican?

Where is your doctor affiliated? (Example: Aurora, Ascension, Froedert, etc.)

Who is your current dentist?

Please provide any additional details you think might be helpful here -- Details are helpful! Or if you have questions or want to clarify any information, this is the place!

Signature

At Covered Bridge Insurance, we are independent agents and offer a wide range of products to ensure the best fit for our clients. However, we do not offer every plan available in your area. Currently, we represent 12 organizations which offer 67 products in your area (WI). Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program for help with plan options.

How did you hear about Covered Bridge Insurance?

My 2024 Prescription Medication List for Review