Medicare Prescription Drug List
Please enter your information and prescriptions below:
Name
*
First Name
Last Name
Birthdate
-
Month
-
Day
Year
Date
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Current pharmacy
*
Other convenient pharmacies
You may upload an image of your drug list here or enter medications below.
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of
Medication #1
Medication #2
Medication #3
Medication #4
Medication #5
Medication #6
Medication #7
Medication #8
Medication #9
Medication #10
List any additional medications or (Physician Names here for Advantage Plans Only)
If you need help affording any medicines please enter the names here.
Would you like help applying for a low income subsidy, medicaid or pharmaceutical assistance based on financial need?
I acknowledge that I have received a copy of DMIA Privacy Notice located at dougmcculloughinsuranceagency.com/privacy. I also agree to be contacted about prescription drug coverage. E-Signature (Type Name below)
E Signature (Please type your name here)
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