Doctor and Medication Intake form

Glidden Group Health Insurance

402 W Canfield Ave., Suite 2, Coeur d Alene, ID 83815

401 Bonner Mall Way, Suite K, Ponderay, ID 83852

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
If absolutely nothing has changed since last year, please indicate that here!
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 2027 year?
Medications

Only your medications that you receive from a Pharmacy

MEDICATION LIST