Medicare Part D Plan Comparison
Patient's Full Name
*
First Name
Middle Name
Last Name
Suffix
Patient's Birth Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Patient's Medicare Number or Social Security Number
Is the patient a resident of a long-term care facility?
Yes
No
If yes, please list the name of the facility:
Current Medication List
Please upload a file or type the list of current medications. Please include medication name, strength, and frequency for all medications you are currently taking. Example: lisinopril 10mg 1 tablet once a day
Attach a copy of your medication list
Browse Files
Cancel
of
Type your current medication list
Additional Information
Any additional information pharmacy staff should be aware of that may impact Medicare Part D Drug Plan selection? IE. obtaining a medication from a different pharmacy, plan to start a new medication, etc.
Additional Information
Any additional information pharmacy staff should be aware of that may impact Medicare Part D Drug Plan selection? IE. obtaining a medication from a different pharmacy, plan to start a new medication, etc.
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