Annual Medicare Review | Reich Insurance

Complete our Annual Medicare Review form below and a member of our team will reach out to you shortly.

Full Name*
Address*
Email*
Phone*
List of Medications (please list the complete name of medication as shown on your prescription including dosage and quantity per day. Example: Metoprolol Succinate ER, 50 MG, 1 x daily) If no current medications type “none”.*
Preferred Pharmacy (list the pharmacy name you use to obtain your prescriptions. If you prefer mail order, please provide a pharmacy name in the event you would need to go to a pharmacy)*
Do you ever use mail order?*
- Yes
- No
Current Prescription Plan (please provide name of plan and premium if known – i.e. Humana – $14.00. If unsure, leave blank)*
Would you also like us to review your Medical Plan?*
- Yes
- No
If yes, please provide current carrier and plan premium – i.e. New Era – $200 per month.*
Is there anything else you would like us to know, or to take into consideration?
Comments
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