Medicare Needs Analysis

MEDICARE NEEDS ANALYSIS

PERSONAL INFORMATION
Full Name*
Date of Birth*

MonthDayYear
Date
Address*

Street Address

County

CityState

Zip Code
City*
State*
Zip*
Home Phone
Cell/Mobile Phone
Email
example@example.com
Referred by
Medicaid ID (if applicable)
Medicare ID (if applicable)
Part A Effective Date

MonthDayYear
Date
Part B Effective Date

MonthDayYear
Date

CURRENT MEDICARE PLANS (if applicable)
Do you have a...*

Medicare Supplement PlanMedicare Advantage PlanNo current Medicare plan
Medicare Supplement Plan
Premium paid ($ per month)
Prescription Drug Plan
Premium paid ($ per month)
Medicare Advantage Plan
Premium paid ($ per month)
Current Dental/Vision/Hearing Benefit(s):
May be included by Advantage Plan
Additional Benefits Provided:
i.e. transportation, gym membership, over-the-counter cards, etc.

PRESCRIPTIONS
Preferred Pharmacy*
Optional:

Through their partnership with Tomahawk Pharmacy, LLC, I hereby consent Patient's Choice Health Agency to contact Tomahawk Pharmacy to request the release of any information regarding my prescriptions and prescription history

Please all of your current prescriptions and their cost to fill per month

	Drug Name	Strength	Qty/month	Cost/month
#1
#2
#3
#4
#5
#6
#7
#8
#9
#10
#11
#12
#13
#14
#15
#16
#17
#18
#19
#20
#21
#22
#23
#24

RECOGNITION OF INDEPENDENT BUSINESSES
The following distinct and independent entities operate within the same location.
- Pharmacy Details
  Tomahawk Pharmacy
  315 W Wisconsin Ave
  Tomahawk, WI 54487
  (715) 453-6600
  pharmacy@tomahawkpharmacy.com
- Medicare Consultation Business Details
  Patient's Choice Health Agency
  315 W Wisconsin Ave
  Tomahawk, WI 54487
  (715) 504-0550
  agent@pchagency.com
While these two businesses may share ownership, personnel, or physical space, they remain distinct entities with their own specific roles, operations, and services.
- Pharmacy Services
  The pharmacy provides services such as dispensing medications, offering drug information, counseling, managing medication therapy, immunizations, health screenings, and advice on over-the-counter products. These services are designed to ensure the safe and effective use of medications, tailored to the needs of each patient.
- Medicare Consultation Services
  The Medicare Consultation business focuses on assisting client with Medicare-related needs, including plan selection, enrollment, and consultations on various Medicare matters.
This document serves as commitment to transparency regarding the independent operations of the pharmacy and the Medicare consultation business. Despite any shared resources or personnel, each business adheres to its own regulations, guidelines, and ethical standards, preserving their unique identities and services.
I, blanks*, (please type your name), hereby acknowledge the existence of the above mentioned distinct and independent entities operating within the same location.
Client or Legal Representative Signature*

Clear
Relationship*

SelfOther
Date

MonthDayYear
Date
Should be Empty:

	Drug Name	Strength	Qty/month	Cost/month
#1
#2
#3
#4
#5
#6
#7
#8
#9
#10
#11
#12
#13
#14
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#17
#18
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#20
#21
#22
#23
#24

	Drug Name	Strength	Qty/month	Cost/month
#1
#2
#3
#4
#5
#6
#7
#8
#9
#10
#11
#12
#13
#14
#15
#16
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#18
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#20
#21
#22
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#24

MEDICARE NEEDS ANALYSIS

	Drug Name	Strength	Qty/month	Cost/month
#1
#2
#3
#4
#5
#6
#7
#8
#9
#10
#11
#12
#13
#14
#15
#16
#17
#18
#19
#20
#21
#22
#23
#24