​

 

The Part D coverage with Medicare is constantly changing from year to year and medications are the area our clients seem to use the most. That's why it is imperative that you have the best plan for you. To facilitate that, this form will ensure we have the most accurate information. 

​

Please list all medications, dosages and frequency. Pills, capsules, creams, injections, eyedrops. 

​

Also include the names of the pharmacy or pharmacies you use. If you prefer mail order, indicate that. 

​