Standalone Drug Plan Review Form Enrollment Starts October 15, 2020IMPORTANT: Medicare Open Enrollment Ends: December 7, 2020 FacebookThis field is for validation purposes and should be left unchanged.Name*Phone*Address Street City State / Province / Region ZIP / Postal Code Email* Date of Birth Your PharmacyYour Current Drug PlanLIST OF MEDICATIONS Please fill out the list of your current medications including: Name, dosage (mg), Number of Times Taken Per Day in order to get the drug review. Completing this form will not prevent you from enrolling into any plan of your choice for which you are eligible.MEDICATIONS #1 NAME OF MEDICATIONBRAND Brand GENERIC GENERIC DOSAGE (MG)NUMBER OF TIMES TAKENPer Day/Month/Year (Circle)MEDICATIONS #2 NAME OF MEDICATIONBRAND Brand GENERIC GENERIC DOSAGE (MG)NUMBER OF TIMES TAKENPer Day/Month/Year (Circle)MEDICATIONS #3 NAME OF MEDICATIONBRAND Brand GENERIC GENERIC DOSAGE (MG)NUMBER OF TIMES TAKENPer Day/Month/Year (Circle)MEDICATIONS #4 NAME OF MEDICATIONBRAND Brand GENERIC GENERIC DOSAGE (MG)NUMBER OF TIMES TAKENPer Day/Month/Year (Circle)MEDICATIONS #5 NAME OF MEDICATIONBRAND Brand GENERIC GENERIC DOSAGE (MG)NUMBER OF TIMES TAKENPer Day/Month/Year (Circle)MEDICATIONS #6 NAME OF MEDICATIONBRAND Brand GENERIC GENERIC DOSAGE (MG)NUMBER OF TIMES TAKENPer Day/Month/Year (Circle)MEDICATIONS #7 NAME OF MEDICATIONBRAND Brand GENERIC GENERIC DOSAGE (MG)NUMBER OF TIMES TAKENPer Day/Month/Year (Circle)MEDICATIONS #8 NAME OF MEDICATIONBRAND Brand GENERIC GENERIC DOSAGE (MG)NUMBER OF TIMES TAKENPer Day/Month/Year (Circle)MEDICATIONS #9 NAME OF MEDICATIONBRAND Brand GENERIC GENERIC DOSAGE (MG)NUMBER OF TIMES TAKENPer Day/Month/Year (Circle)MEDICATIONS #10 NAME OF MEDICATIONBRAND Brand GENERIC GENERIC DOSAGE (MG)NUMBER OF TIMES TAKENMEDICATIONS #11 NAME OF MEDICATIONBRAND Brand GENERIC GENERIC DOSAGE (MG)NUMBER OF TIMES TAKENPer Day/Month/Year (Circle)SignatureYour NameYour NameYour NameYour NameDate CAPTCHA
