MEDICARE REVIEW FORM
THIS FORM IS HIPAA COMPLIANT AND IS SENT AND STORED ON A SECURE SERVER.
REQUESTED EFFECTIVE DATE
*
-
Month
-
Day
Year
Date
FULL NAME
*
DATE OF BIRTH
*
/
Month
/
Day
Year
PHONE NUMBER
*
EMAIL ADDRESS
*
example@example.com
PHYSICAL ADDRESS
*
UNIT/APT #
CITY
*
STATE
*
ZIP CODE
*
COUNTY
*
DO YOU HAVE A DIFFERENT MAILING ADDRESS?
*
Please Select
YES
NO
MAILING ADDRESS
*
UNIT/APT #
CITY
*
STATE
*
ZIP CODE
*
DO YOU CURRENLTY HAVE MEDICARE PART A AND B?
*
Please Select
YES
NO
MEDICARE NUMBER
*
PART A EFFECTIVE DATE
/
Month
/
Day
Year
NOTE IF A FIELD DOES NOT APPLY TO YOU, PLEASE MARK NA.
NA
PART B EFFECTIVE DATE
/
Month
/
Day
Year
NOTE IF A FIELD DOES NOT APPLY TO YOU, PLEASE MARK NA.
NA
WHAT TYPE OF PLAN ARE YOU CURRENTLY ON?
Please Select
MEDICARE ADVANTAGE PLAN
MEDICARE SUPPLEMENTAL PLAN
ORIGINAL MEDICARE ONLY
INDIVIDUAL HEALTH INSURANCE
GROUP HEALTH INSURANCE
FULL PLAN NAME (NOT JUST CARRIER NAME)
*
DO YOU CURRENTLY HAVE A MEDICARE PRESCRIPTION DRUG PLAN?
*
Please Select
YES
NO
FULL PLAN NAME (NOT JUST CARRIER NAME)
PREFERRED PHYSICAL PHARMACY
*
DO YOU TAKE ANY PRESCRIPTION DRUGS?
*
Please Select
YES
NO
PRESCRIPTION DRUGS (DO NOT INCLUDE OVER THE COUNTER DRUGS OR DRUGS ADMINISTERED IN A DOCTORS OFFICE. PLEASE ENTER FULL NAME OF THE DRUG FROM THE BOTTLE AS MANY DRUG NAMES ARE USED IN MULTIPLE DRUGS. FOR DRUG TYPE PLEASE PUT CAPSULE, TABLET, VIAL, PEN, INHALER ETC.
FULL DRUG NAME
DRUG TYPE
DOSAGE IN MG
# PER MONTH
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20
DOCTOR'S INFORMATION (PLEASE NOTE WE NEED THE FULL NAME OF THE DOCTOR. IF YOU USE A PHYSICIAN'S ASSISTANT OR NURSE PRACTIONER, WE NEED THE MAIN MD IN THE OFFICE.)
DOCTOR'S FIRST AND LAST NAME
SPECIALTY
ADDRESS(ADDRESS& ZIP, NO CITY OR STATE)
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