2016 Medicare Rx Drug Coverage Form
If you plan on seeing a Medicare counselor you will need to print and fill out this form and bring it with you.
Content
MEDICARE PRESCRIPTION DRUG COVERAGE WORKSHEET
1.
What is your name as it appears on your Medicare card?
2.
What is your Medicare claim number?
3.
What is your date of birth? ___ ___/___ ___/___ ___ ___ ___
4.
What is the effective date for your Medicare?
Part A __ __/__ __/__ __ __ __ Part B __ __/__ __/__ __ __ __
8.
What is your preferred pharmacy?
____________________________________________________________
5.
What is your address? ___________________________________________________________
City, State, Zip Code _____________________________________________________________
To help determine your eligibility for Extra Help with Medicare Part D costs please answer the
next two
questions.
Phone
# _________________________________________
Single,
widowed,
or live
apart from
Married
6.
What
countydivorced
do you live
in? _________________________
spouse
___ Our take?
annual
gross income
$23,265
7.
What prescription medications do you currently
(Please
also list is
dosage
andor
how
___
My
annual
gross
income
is
$17,235
or
less
many you take in 1 month.
less
___ Our annual gross income is greater than
PLEASE PRINT CLEARLY
___ My annual gross income is greater than
$23,265
$17,235
DRUG NAME
DOSAGE
30-DAY
QUANTITY
Liquid assets are the total value of your savings, investments and real estate. Do not include
your primary home, vehicles, burial plots or personal possessions.
Single, widowed, divorced or live apart from
spouse
___ My assets are $13,300 or less
Married
___ Our assets are $26,580 or less
___ Our assets are greater than $26,580
___ My assets are greater than $13,300
SHICK Disclaimer
SHICK Volunteer Name: ____________________________________
SHICK Volunteer Telephone: ________________________________
I have reviewed at least 3 Medicare Part D Prescription Drug Plans and have chosen
the following plan:
_________________________________________________________________________________
and I give the SHICK volunteer my authorization to enroll me in the above plan
using the information I have provided. I confirm that all information provided is
truthful and accurate and I confirm that I will not hold the SHICK volunteer
responsible for my decision nor will I have the volunteer or the SHICK organization
responsible for any liability rising our of assisting me in my enrollment.
I understand that I may not change my drug plan until the next open enrollment
period which will be
October 15, 2015 to December 7, 2016
I also understand the costs and covered medications quoted on the plan I’ve chosen
are subject to change.
Signature:________________________________ Printed Name:
_______________________________
1.
What is your name as it appears on your Medicare card?
2.
What is your Medicare claim number?
3.
What is your date of birth? ___ ___/___ ___/___ ___ ___ ___
4.
What is the effective date for your Medicare?
Part A __ __/__ __/__ __ __ __ Part B __ __/__ __/__ __ __ __
8.
What is your preferred pharmacy?
____________________________________________________________
5.
What is your address? ___________________________________________________________
City, State, Zip Code _____________________________________________________________
To help determine your eligibility for Extra Help with Medicare Part D costs please answer the
next two
questions.
Phone
# _________________________________________
Single,
widowed,
or live
apart from
Married
6.
What
countydivorced
do you live
in? _________________________
spouse
___ Our take?
annual
gross income
$23,265
7.
What prescription medications do you currently
(Please
also list is
dosage
andor
how
___
My
annual
gross
income
is
$17,235
or
less
many you take in 1 month.
less
___ Our annual gross income is greater than
PLEASE PRINT CLEARLY
___ My annual gross income is greater than
$23,265
$17,235
DRUG NAME
DOSAGE
30-DAY
QUANTITY
Liquid assets are the total value of your savings, investments and real estate. Do not include
your primary home, vehicles, burial plots or personal possessions.
Single, widowed, divorced or live apart from
spouse
___ My assets are $13,300 or less
Married
___ Our assets are $26,580 or less
___ Our assets are greater than $26,580
___ My assets are greater than $13,300
SHICK Disclaimer
SHICK Volunteer Name: ____________________________________
SHICK Volunteer Telephone: ________________________________
I have reviewed at least 3 Medicare Part D Prescription Drug Plans and have chosen
the following plan:
_________________________________________________________________________________
and I give the SHICK volunteer my authorization to enroll me in the above plan
using the information I have provided. I confirm that all information provided is
truthful and accurate and I confirm that I will not hold the SHICK volunteer
responsible for my decision nor will I have the volunteer or the SHICK organization
responsible for any liability rising our of assisting me in my enrollment.
I understand that I may not change my drug plan until the next open enrollment
period which will be
October 15, 2015 to December 7, 2016
I also understand the costs and covered medications quoted on the plan I’ve chosen
are subject to change.
Signature:________________________________ Printed Name:
_______________________________
