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Medicare Benefit Check-Up

Medicare Benefit Check-Up Form

Your Name
MM slash DD slash YYYY
Spouse’s Name
MM slash DD slash YYYY
Please list all of your current medications as they are written on your medication bottles (list Generic names if used.) List only medications prescribed by your doctor and do not include over the counter items. Example: Rx Name – Lisinopril, Dosage – 20 mg, How Often – 2 X a day
Rx Name
Dosage
How Often
 
Spouse’s Prescriptions
Rx Name
Dosage
How Often
 
Consent
This field is for validation purposes and should be left unchanged.

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