Please list each prescription medication you take regularly. We’ll ask the following for each med.

• Name 
• Dosage
• How the prescription is filled and it's quantity (30 tabs, 1 tube, 1 box of 4 pens)
• How often you refill the prescription

⚠️ Generics will be used unless "Brand Only" is included on the medication name line
Example: "Brand Only Lipitor" or we will enter it's generic Atorvastatin

Don’t worry if you are unsure, we’ll review your entries and reach out if we have questions.

Privacy & Purpose Statement

The information you provide in this form will be used only by Saving Seniors Money to help you review your Medicare coverage during the Annual Enrollment Period.

We will never share your medication list, contact details, or any personal health data with anyone outside our team. Your entries are secure, protected, and reviewed only by your Saving Seniors Money team.