Medicare Enrollment Patient Questionnaire
Counselling available Fridays and Saturdays or by appointment (937)766-2273
Name *
Address *
Phone number *
Do you fill any prescriptions at other pharmacies (Mail-order, Retail) *
If yes to previous question, where?
What prescriptions do you regularly take? (name of drug, strength and directions on bottle) *
Would you prefer to keep your prescriptions at Cedar Care? *
Do you get help with your costs from one of these programs?
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Do you know what a deductible is?
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Do you know what a  premium is?
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Do you know what a co-pay is?
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Would you prefer to have a Part D plan or a Medicare Advantage plan
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Do you know your Medicare number and effective dates?
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If yes to previous question, please list your Medicare number and effective dates.
Date of availability to discuss your plan comparison report. (Fridays 10am to 5pm and Saturdays 9am to 1pm) Or by appointment
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This form was created inside of Cedarville University.