Clone of Clone of Rick Drug Form'27

1
Name* This field is required.
First Name
Last Name
2
Phone Number* This field is required.
Area Code
Phone Number
3
Email* This field is required.Required - We will send your results to this email address.
example@example.com
4
What is the name of your current Part D or Advantage Plan?Example: Wellcare Value Script, United Healthcare HMO, Blue Cross Blue Shield Access PPO, etc...
5
What is your current plans monthly premium?
6
What pharmacy do you currently use?* This field is required.
7
Willing to switch pharmacies?* This field is required.We will send a price comparison between your current and recommended pharmacies for you to decide if it's worth it.
YESNO
8
Do you currently take any prescription medications?
YESNO
9
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 (Monthly, 90 days, PRN, etc...)

The form will accept 12 Medications. If needed, add the remaining prescription details in the Notes section at the end.

⚠️ 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.
10
Medication 1 Detail* This field is required.
Medication Name
Dosage
Quantity Filled
Please Select
Please Select
30 Days
60 Days
90 Days
6 Months
Annually
PRN
Refill Frequency
11
Add A Second Medication?* This field is required.
YESNO
12
Medication 2 Detail
Medication Name
Dosage
Quantity Filled
Please Select
Please Select
30 Days
60 Days
90 Days
6 Months
Annually
PRN
Refill Frequency
13
Add A Third Medication?* This field is required.
YESNO
14
Medication 3 Detail
Medication Name
Dosage
Quantity Filled
Please Select
Please Select
30 Days
60 Days
90 Days
6 Months
Annually
PRN
Refill Frequency
15
Add A Fourth Medication?* This field is required.
YESNO
16
Medication 4 Detail
Medication Name
Dosage
Quantity Filled
Please Select
Please Select
30 Days
60 Days
90 Days
6 Months
Annually
PRN
Refill Frequency
17
Add A Fifth Medication?* This field is required.
YESNO
18
Medication 5 Detail
Medication Name
Dosage
Quantity Filled
Please Select
Please Select
30 Days
60 Days
90 Days
6 Months
Annually
PRN
Refill Frequency
19
Add A Sixth Medication?* This field is required.
YESNO
20
Medication 6 Detail
Medication Name
Dosage
Quantity Filled
Please Select
Please Select
30 Days
60 Days
90 Days
6 Months
Annually
PRN
Refill Frequency
21
Add A Seventh Medication?* This field is required.
YESNO
22
Medication 7 Detail
Medication Name
Dosage
Quantity Filled
Please Select
Please Select
30 Days
60 Days
90 Days
6 Months
Annually
PRN
Refill Frequency
23
Add A Eighth Medication?* This field is required.
YESNO
24
Medication 8 Detail
Medication Name
Dosage
Quantity Filled
Please Select
Please Select
30 Days
60 Days
90 Days
6 Months
Annually
PRN
Refill Frequency
25
Add A Ninth Medication?* This field is required.
YESNO
26
Medication 9 Detail
Medication Name
Dosage
Quantity Filled
Please Select
Please Select
30 Days
60 Days
90 Days
6 Months
Annually
PRN
Refill Frequency
27
Add A Tenth Medication?* This field is required.
YESNO
28
Medication 10 Detail
Medication Name
Dosage
Quantity Filled
Please Select
Please Select
30 Days
60 Days
90 Days
6 Months
Annually
PRN
Refill Frequency
29
Add A Eleventh Medication?* This field is required.
YESNO
30
Medication 11 Detail
Medication Name
Dosage
Quantity Filled
Please Select
Please Select
30 Days
60 Days
90 Days
6 Months
Annually
PRN
Refill Frequency
31
Add A Twelfth Medication?* This field is required.
YESNO
32
Medication 12 Detail
Medication Name
Dosage
Quantity Filled
Please Select
Please Select
30 Days
60 Days
90 Days
6 Months
Annually
PRN
Refill Frequency
33
Any notes or additional info you would like to share with us?
Huge
Large
Normal
Small
Ok
Ok
34
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.
35
I understand and agree to the use of this form as described* This field is required.
Yes I understand and agree.
Should be Empty: