If you would like to have a Medicare Prescription Drug Plan check-up, please fill out the form below and I will get back to you as quickly as I can.

Your Name (required):

Address (required):

Zip Code (required):

Email Address (required):

Phone Number (required):

Effective Date for Hospital (Part A) Coverage (required):

Effective Date for Medical (Part B) Coverage (required):

Do You Have Prescription Coverage Now? (required)

Current Carrier (required):

Current Plan (required):

Your Favorite Pharmacy (required):

Having a Part D plan is optional, but Denise highly recommends it. If you are currently not taking prescription meds, but want coverage to avoid the penalty, please choose Yes here: and Denise will send information on inexpensive options.

Current Prescriptions

Drug Name:
Dosage:
Number Per Day:
Generic O.K.?
Monthly Cost:

 

Drug Name:
Dosage:
Number Per Day:
Generic O.K.?
Monthly Cost:

 

Drug Name:
Dosage:
Number Per Day:
Generic O.K.?
Monthly Cost:

 

Drug Name:
Dosage:
Number Per Day:
Generic O.K.?
Monthly Cost:

 

Drug Name:
Dosage:
Number Per Day:
Generic O.K.?
Monthly Cost:

 

Drug Name:
Dosage:
Number Per Day:
Generic O.K.?
Monthly Cost:

 

Drug Name:
Dosage:
Number Per Day:
Generic O.K.?
Monthly Cost:

Drug Name:
Dosage:
Number Per Day:
Generic O.K.?
Monthly Cost:

 

Drug Name:
Dosage:
Number Per Day:
Generic O.K.?
Monthly Cost:

 

Drug Name:
Dosage:
Number Per Day:
Generic O.K.?
Monthly Cost:

 

Drug Name:
Dosage:
Number Per Day:
Generic O.K.?
Monthly Cost:

 

Drug Name:
Dosage:
Number Per Day:
Generic O.K.?
Monthly Cost:

 

Drug Name:
Dosage:
Number Per Day:
Generic O.K.?
Monthly Cost:

 

Drug Name:
Dosage:
Number Per Day:
Generic O.K.?
Monthly Cost: