Doctor and Medication Intake form

Glidden Group Health Insurance

402 W Canfield Ave. Coeur d Alene, Idaho 83815

PHONE: 208-962-0077
MEDICATION LIST

PLEASE PROVIDE AN UPDATED, ACCURATE AND COMPLETE LIST OF ALL YOUR MEDICATIONS.
By completing this form, you are authorizing Glidden Group Health Insurance to analyze your prescription drug utilization and are requesting a recommendation for your health plan and giving us approval to follow up via a call and/or an email regarding your health plan options.

I understand that I am volunteering this prescription medication information to evaluate my prescription drug coverage options. This information is completely confidential.
*Type your Name here*

First NameMiddle NameLast NameSuffix (Jr, Sr, III, ect)
Today's Date*

MonthDayYear
Date
Gender*
Birth Date*

MonthDayYear
E-Mail*

Confirmation EmailConfirm E-mail
Zip Code*
What County do you live in?*
Phone Number*
Format: (000) 000-0000.
Primary Care Physician
First Last
List of other doctors and specialists
Preferred Pharmacy
Are you eligible for Medicaid or Low Income Subsidy?
Do you have any special needs or concerns that we should know about for the 2026 year?
Medications

Only your medications that you receive from a Pharmacy

Please verify the spelling when adding your medications.

MEDICATION LIST