Medicare Part D Questionnaire

Medicare Part D Questionnaire

This information will help us give you the best cost comparison for your needs
*You are not required to provide any private, protected health information (PHI). The below requested information is for use by Mark E. Werner, MSFS, CFP, RICP, RICP, CLU, ChFC only to help you make an informed plan decision and will not be shared with any third party.

You will be providing the PHI voluntarily and without coercion from Mark E. Werner, MSFS, CFP, RICP, CLU, ChFC.*
Name *

First Name Last Name
Email *
example@example.com
Preferred Phone #

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Birthdate: *
Medicare Claim # (found on your Medicare Card/ type "N/A" if you don't have yours yet) *
Part A Effective Date (Type "N/A" if you don't have one yet) *
Part B Effective Date (Type "N/A" if you don't have one yet) *
Do you use Mail Order? *

I use mail order for ALL of my Rx drugs I use a combination of Brick & Mortar pharmacies + Mail Order I only use brick & mortar to pick up my Rx drugs
Which Brick & Mortar pharmacy do you prefer? EVEN IF YOU USE MAIL ORDER, please indicate a pharmacy. FOR EXAMPLE: Let's say you needed antibiotics, where would you drive in town to get them? *Please note we cannot search for the lowest priced pharmacy. There are far too many variables and the system doesn't sort that way. Please indicate your preferred brick & mortar pharmacy (please list no more than 2)* *
If you're already on a Part D Plan how do you pay for it? If you're not yet, how do you prefer to pay for it going forward?

Auto Deduction I get a monthly bill Comes out of Social Security I'm not sure!
Next, we need a list of your Rx drugs.

We need to know:
- THE NAME OF THE DRUG
- WHETHER IT IS BRAND NAME OR GENERIC (if you don't know, please call your pharmacy. WE won't know that answer, and it can mean the difference of thousands of dollars!)
- THE DOSAGE
- HOW MANY TIMES PER DAY YOU TAKE THIS Rx DRUG (time of day does not matter, we just need to know quantity)
- The MORE you give us that the bottle says, the more we can be sure we match your exact dosage and needs
- You won't necessarily fill out all of these (some of you will fill out none of these because you aren't currently taking any Rx medication), once you've entered in every Rx drug you are currently having filled, scroll to the bottom and hit SUBMIT
- If you are currently prescribed more than 15 Rx drugs, you may include more than 1 in each box.
EXAMPLE:

Rx Drug Name, generic, .5mg, 1 tablet per day

Rx Drug Name, brand, 50mcg, 3 capsules per day

Rd Drug Name, generic, 10mg, the directions are 3x per day, but I only take as needed and take about 5 tablets a month.
Please list Rx Drug 1
Please list Rx Drug 2
Please list Rx Drug 3
Please list Rx Drug 4
Please list Rx Drug 5
Please list Rx Drug 6
Please list Rx Drug 7
Please list Rx Drug 8
Please list Rx Drug 9
Please list Rx Drug 10
Please list Rx Drug 12
Please list Rx Drug 13
Please list Rx Drug 14
Please list Rx Drug 15
Should be Empty: