Home > RX and Physician Intake

RX and Physician Intake

RX and Physicians Information

* indicates required fields

Name*

Email*

Phone*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Current Plan:

Preferred Pharmacy:

Prescription Drug Medications

Please list all prescription medications - please do not include over the counter medications. If you are currently using any discount programs or grant programs such as Good Rx or drug manufacturers coupons please note which prescriptions and what discount program in the notes section at the bottom of this form.

Please List All Prescription Medications

Drug Name:

Dosage:

Times/Day:

Example: Drug A - 12mg/1 tablet - morning/night. Please click the plus sign to add any additional medications.

Providers

Please List All Physician Providers:

We do not need provider information for Part D review. Please only complete this section if you are interested in or reviewing your Medicare Advantage plan. **Also, please click the plus sign to add additional providers.

First and Last Name:

Specialty

City

Please provide any additional details:

CAPTCHA

Post Custom Field

Comments

This field is for validation purposes and should be left unchanged.

We Want Your Opinion!

Customer Reviews

Buck Walker was great. I could not have asked for a better agent.

Don G

 5/5

They staff is knowledgable, respectful, patient and kind.

SM B

 5/5

Amazing people and service!

Daphne A

 5/5

Great people to deal with!

Colton P

 5/5

Thank you for your kindness and all the help.

P S

RX and Physician Intake

RX and Physicians Information

Prescription Drug Medications

Providers

Buck Walker was great. I could not have asked for a better agent.

They staff is knowledgable, respectful, patient and kind.

Amazing people and service!

Great people to deal with!

Thank you for your kindness and all the help.

Contact

Insurance

About

Policy Service