Provider and Prescription Listing
To help us recommend coverage for you, please list your doctors, prescriptions and preferred facilities below. We will prioritize plans that include your preferred providers whenever possible. However, final network participation and drug formularies should always be confirmed directly with the insurance carrier.
What is your name?
First Name
Last Name
What is your email?
example@example.com
What is your phone number?
Please enter a valid phone number.
Format: (000) 000-0000.
Who is your Primary Care Provider?
Rows
Doctor Name
Address
1
Please list your specialists.
Rows
Doctor Name
Specialty
Address
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2
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9
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Who is your dentist?
Rows
Dentist Name
Address
1
2
What hospital or medical facilities do you prefer do use?
Rows
Name of Hospital
Address
1
2
3
4
Please list your prescriptions that you take routinely or occasionally.
Rows
Prescription Name
Dosage
Type of Drug (tablet, capsule, injection, cream, etc.)
How often do you take this drug?
1
2
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10
What pharmacy do you prefer to use?
Rows
Name of Pharmacy
Address
1
Is there any other information about your preferred providers, prescriptions, or facilities that you would like to provide?
If you need to provide more information, please email the information to sarah@laughlinagency.com.
Submit
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