Request New to Medicare Packet

Request New To Medicare Packet

Request New to Medicare Packet

An informational packet discussing Medicare Part A (Hospital coverage) Part B (Outpatient Medical), Part C (Advantage Plans) and Part D (Prescription Drug Plans) as well as Medicare supplements and other resources will be mailed out to you. The packet can be used alone or in conjunction with the online Medicare videos. Washington County residents only.

First Name

Last Name

Date of Birth (MM/DD/YYYY)

Address

City/State/Zip Code

Email (if available)

Phone Number

Current Plan

Start Date: Medicare Part A

Start Date: Medicare Part B

Local Pharmacy Preference-Choose up to 2 pharmacies

(If no selection, will default to Walgreens Pharmacy)

If you wish to have a customized prescription plan comparison done for you utilizing the www.medicare.gov

website, provide a complete prescription medication list - including Name/Dosage/Frequency for each drug.

(Example: Lisinopril 10mg 1 per day)

If a drug is used "as needed" please indicate how often script is filled, ie: every 3 months, once per year, etc.

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