Medicare Plan Review Appointment Request - Annual Open Enrollment - Paris
1814 Paris Road - Columbia MO (Inside D&H Drug Store)
Appointment
*
Medicare Beneficiary Name
*
First Name
Last Name
I prefer the following appointment type:
*
In Person
Phone
Video Call (e.g. Zoom)
Phone Number
Please enter a valid phone number. - Required if phone appointment requested
Format: (000) 000-0000.
Email
Required if Video Call Requested
I give permission for my pharmacy to share my prescription records with a representative of Two Med Advisors.
*
Yes
No
Preferred Pharmacy Name
Preferred Pharmacy Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: