COMPLETE FORM - Griset Medicare Solutions

Drug Name (e.g., Lipitor)	Strength (e.g., 250 mg)	Dosage (e.g., 1/day)
Your Full Name:
Address/Zip Code:
Date of Birth:
Email Address:
Main Phone:
Cell Phone:
Tell Us About Your Medicare Coverage:
Current Health Plan:	Premium/Mo: $	Group Plan: Yes No
Current Drug Plan:	Premium/Mo: $	Group Plan: Yes No
Current Dental Plan:	Premium/Mo: $	Group Plan: Yes No
Current Vision Plan:	Premium/Mo: $	Group Plan: Yes No
Enrolled in a HSA Plan:	Yes No
Your Primary Physician Name and Address:
Your Medical Specialists and Addresses:
Your Hospital Preference and Location:
Your Dentist Name and Address:
Your effective dates of Medicare Parts A and/or B:	Effective Date of Part A
Your effective dates of Medicare Parts A and/or B:	Effective Date of Part B
YOUR CURRENT MAINTENANCE MEDICATIONS:

Please complete as much of this form to the best of your knowledge. We will contact you to discuss any further information required. This information will be kept and protected for the sole and confidential use of Griset Medicare Solutions.