Medicare Questionnaire
Please complete this form so that we may prepare for your Medicare review:
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 or document your drug list or provider list here or enter medications below.
Browse Files
Click here to attach a file
Cancel
of
Medication #1
Medication #2
Medication #3
Medication #4
Medication #5
Medication #6
Medication #7
Medication #8
Medication #9
Medication #10
Enter physician names here Medicare Advantage Plans only
List additional prescriptions 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 Medicare prescription drug coverage. E-Signature (Type Name below)
E Signature (Please type your name here)
Submit
Should be Empty: