Contact Information (Please be as complete as possible)

Name Town Zip Code

(Outside of Connecticut? Click Here to be redirected to Medicare's national Drug Finder website)

How would you like to be informed of your best drug plan options?

1) Email address (doe@server.com)

2) Phone (555-555-5555) Extension

3) Mail (street address)

Prescription Information (list the drugs you currently take)

Date coverage is to begin August 1, 2011 September 1, 2011 October 1, 2011 November 1, 2011 December 1, 2011 January 1, 2012 February 1, 2012 March 1, 2012 April 1, 2012 May 1, 2012 June 1, 2012 July 1, 2012 August 1, 2012 September 1, 2012 October 1, 2012 November 1, 2012 December 1, 2012 January 1, 2013 February 1, 2013 March 1, 2013 April 1, 2013 May 1, 2013 June 1, 2013 July 1, 2013 August 1, 2013 September 1, 2013 October 1, 2013 November 1, 2013 December 1, 2013 January 1, 2014

Prescription #1   Dosage Taken daily 1/2 1 1 1/2 2 3 4 5 6
Prescription #2   Dosage Taken daily 1/2 1 1 1/2 2 3 4 5 6
Prescription #3   Dosage Taken daily 1/2 1 1 1/2 2 3 4 5 6
Prescription #4   Dosage Taken daily 1/2 1 1 1/2 2 3 4 5 6
Prescription #5   Dosage Taken daily 1/2 1 1 1/2 2 3 4 5 6
Prescription #6   Dosage Taken daily 1/2 1 1 1/2 2 3 4 5 6
Prescription #7   Dosage Taken daily 1/2 1 1 1/2 2 3 4 5 6
Prescription #8   Dosage Taken daily 1/2 1 1 1/2 2 3 4 5 6
Prescription #9   Dosage Taken daily 1/2 1 1 1/2 2 2 1/2 3 4 5 6
Prescription #10 Dosage Taken daily 1/2 1 1 1/2 2 2 1/2 3 4 5 6
Prescription #11 Dosage Taken daily 1/2 1 1 1/2 2 2 1/2 3 4 5 6
Prescription #12 Dosage Taken daily 1/2 1 1 1/2 2 2 1/2 3 4 5 6

Pharmacy of Choice (what pharmacies are convenient to you)

Pharmacy of Choice #1
Name of Pharmacy Town the pharmacy is located in

Pharmacy of Choice #2
Name of Pharmacy Town the pharmacy is located in

Are you also on Medicaid? Yes        No
Are you on Medicare due to Disability prior to age 65? Yes       No

Buy submitting this form, your are giving Medicare Options, LLC permission to make contact with you for the express purpose of discussing Medicare Advantage plans, Medicare Supplemental Insurance (MediGap) plans, Part D Drug plans, or Medicare Parts A&B, as decided by you in the event of conversation. This is to protect you from receiving information on products or services you did not authorize or permit. We are Certified by Medicare to assist beneficiaries with education and enrollment and we adhere to all Medicare and state insurance rules and regulations.

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