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Prescription Drug Form
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Prescription Drug Form
Please Enter Your Contact Information
First Name
*
Last Name
*
Email Address
*
Address
*
City
*
State
*
AL
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AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
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KS
KY
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ME
MD
MA
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MS
MO
MT
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NJ
NM
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NC
ND
OH
OK
OR
PA
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SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip
*
Phone Number
*
Current Policy
Current Premium
Agent Name
Other Information
Medicaid & Social Security
Do you receive extra help from Medicaid or Social Security?
*
no
yes
---
Medicaid
PARTIAL extra help through social security
FULL extra help through social security
Address and traveling
Do you live at a different address between October 15th and December 7th?
*
no
yes
If yes, please provide the address here
*
:
Insulin & Injections
Do you use insulin or injections?
*
:
no
yes
Name of Insulin
*
:
Pen Size :
Mix/Concentration :
Number in Package :
Number Used Per Month :
Add Another Insulin
Remove
Inhalers & Nebulizers
Do you use an Inhaler or Nebulizer?
*
:
no
yes
Name of Inhaler or Nebulizer
*
:
Size (GM/ML)
*
:
Number Used Per Month
*
:
Add Another Inhaler or Nebulizer
Remove
Creams, Gels, Ointments, Lotions & Shampoos
Do you use medicated creams, gels, ointments, lotions or shampoos?
*
:
no
yes
Product name
*
:
Product Type
*
:
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Cream
Gel
Ointment
Lotion
Shampoo
Solution
Concentration
*
:
Refill Quantity per month/year
*
:
Add Another Cream, Gel, Etc.
Remove
Prescription Information
Do you take medication?
*
:
no
yes
Medication
Drug Name
*
:
Name Brand or Generic
*
:
---
Name Brand
Generic
Dosage
*
:
Type
*
:
tablet
capsule
cream
drop
How Many Per Day
*
:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
How Often Do You Refill
Add Another Medication
Remove Medication
Pharmacy Information
What Are Your Preferred pharmacies:
If prices are cheaper at another pharmacy in my area, I will change pharmacies:
*
yes
no
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