Part D Application

PROVIDING INFORMATION IS COMPLETELY OPTIONAL & WILL BE USED SOLELY TO PROVIDE ASSISTANCE REGARDING MEDICARE SUPPLEMENT / DRUG CARD / MEDICARE ADVANTAGE OPTIONS

Full Name as it appears on Medicare Card

Date of Birth (MM/DD/YYYY)

Phone

Medicare Claim Number

Part A Effective Date (MM/DD/YYY)

Part B Effective Date (MM/DD/YYY)

Residential Street Address

City

Residential Street Address Line 2

Postal / Zip code

Region/State/Province

County

Check if Mailing Address is different

Mailing Street Address

Mailing Street Address Line 2

City

Postal / Zip code

Region/State/Province

Premium Payment (Select One):

Social Security Withdrawal

Auto Bank Draft

Monthly Billing

If Bank Draft Please Complete Below:

Bank Name

Account Holder Name

Routing Number

Account Number

Current Medications

List your Prescription medications here. DO NOT list Over The Counter medications. Provide the exact mediation name – If you take generics list generics, if you take brand name list the brand name. List the name of the medication , the dosage that is prescribed, number of pills/tubes/inhalers you pick up at one time, and how often you fill (pick up) that medication. Must specify whether it is a tablet (tab) or Capsule (Cap). Do not write PRN as we cannot guess at your medication frequency. We need a time period to be able to run the quote. Examples:

Metoprolol Tartrate ER, 50mg, 30 tablets monthly

Clobetasol Propionate Ointment, 0/5%, 60GM Tube 1 every 3 months

Albuterol Sulfate inhaler, 108MCG, 6.7 gm inhaler, 1 a year

Pharmacy Name

List Your Current Medications Here (Include Dosage and Frequency)

Call us at 804-500-9960

contact@vahealthagent.com

We are appointed with all the major national and local carriers to help you find the best options

Part D Application

If Bank Draft Please Complete Below: