Medicare D Consultation Preparation Form
Information provided will not be shared with any 3rd parties and will only be used to choose the best Medicare D plan for you. This is a free service and the pharmacy does not receive any compensation from the insurance industry for this service.
Please complete the questions on this form with as much detail and accuracy as possible.
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Home Address (physical address - no PO Box)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you have a separate mailing address?
No
Yes
Mailing Address (PO Box is allowed)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Personal Email
*
example@example.com
Preferred Contact Phone Number
*
Please enter a valid phone number.
Do You Currently Have Health Insurance?
*
No
Yes
Current Health Insurance Type
*
Job-based health insurance
Private pay health insurance
Medicare
Name of Current Insurance Company
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Next
Date New Medicare Coverage is Needed
*
-
Month
-
Day
Year
Date
Are You Enrolled in Medicare or are you going to be Medicare Eligible in the next three months?
*
No
Yes
Medicare ID Number (if already enrolled in Medicare)
Medicare Part A Effective Date (check your Medicare card)
-
Month
-
Day
Year
Date
Medicare Part B Effective Date (if enrolled - check your Medicare card)
-
Month
-
Day
Year
Date
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Do You Take Prescription Medications Currently?
*
No
Yes
Tell Us About Your Current Prescriptions
Prescription Name (brand required?)
Dosage(cap/tab)
Monthly Quantity
Refill Frequency
Rx 1
Rx 2
Rx 3
Rx 4
Rx 5
Rx 6
Rx 7
Rx 8
Rx 9
Rx 10
Do you want HealthSmart Pharmacy to be your preferred pharmacy?
YES
NO
Is Mail-order Pharmacy Option Important to You?
Yes
No
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How do you want to pay your premium?
*
I want the plan to automatically deduct it from my Social Security.
I want the plan to bill me monthly and I will pay the premium directly to the plan.
Do you know what type of Medicare plan you are interested in?
*
Medicare Advantage (Part C) that includes Part D (which in medical and medication coverage)
Medicare Supplement Part D (which only covers medications)
I do not know yet
Please verify that you are human
*
Have you already spoken with an Insurance Broker or Another Pharmacy to discuss your Medicare or Medicare D plan options?
*
Yes
No
If yes to above question please list who you have already discussed your Medicare option with.
*
Appointment
*
Submit
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