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Medicare Benefit Checkup

Medicare Benefit Check-Up Form

Your Name
First Last
Date of Birth
MM slash DD slash YYYY
Spouse’s Name
First Last
Date of Birth
MM slash DD slash YYYY
Phone
Cell Phone
Zip Code
What do you like about your plan?
What do you dislike about your plan?
What are you looking for in a new plan?
Please list all of your current medications as they are written on your medication bottles (list Generic names if used.) List only medications prescribed by your doctor and do not include over the counter items. Example: Rx Name – Enalapril, Dosage – 20 mg, How Often – 2 X a day
Rx Name Dosage How Often
Top 2 Pharmacies Used (including mail order)
Spouse’s Prescriptions
Rx Name Dosage How Often
Top 2 Pharmacies Used (including mail order)

We Want Your Opinion!