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?
a) Email address (doe@server.com)
b) Phone (555-555-5555) Extension
c) Mail (street address)

Prescription Information (list the drugs you currently take)

Date coverage is to begin December 1, 2009 January 1, 2010 February 1, 2010 March 1, 2010 April 1, 2010 May 1, 2010 June 1, 2010 July 1, 2010 August 1, 2010 September 1, 2010 October 1, 2010 November 1, 2010 December 1, 2010 January 1, 2011 February 1, 2011 March 1, 2011 April 1, 2011 May 1, 2011 June 1, 2011 July 1, 2011 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

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

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