Medicare Rx Enrollment Form 2022 (PDF)

Complete this form and refer to it or bring it with you to your meeting.  
 Forms available at Senior Services, 24 Rope Ferry Road Waterford. 
 Callus to schedule your appointment. All information provided is confidential.  
 
Name:  _______________________________   Phone Number: ______________________             
Address: _______________________________________ 
Zoom/Phone/In-Person: _______________ Email Address:_________________________ 
Do you have Medicare coverage? □  If no, will you have Medicare in the next 3 months? □          
Do you have Original Medicare?  Yes □  No  □  
OR 
Do you have a Medicare Advantage Plan (i.e. HMO, PPO, or Priv. Plan) Yes □  No  
□  
  
If you are enrolled in a Medicare Advantage Plan please provide the company name and ID 
#:___________________________________  
OR 
 
 
 
 
What is your Medicare number: ____________________________  Bring your Medicare Card 
 
Do you have Part A?           Effective Date:    ________________            
                                    
Do you have Part B?           Effective Date:    ________________ 
Current Medicare Rx Plan Name    ___________________________ 
Medicare Rx Number     ( S  _  _  _  _  -  _  _  _  -  _ )    
The State of CT pays my monthly Medicare Part B premiums .      Yes □             No □    
Do you have a Supplemental/Medigap policy? Yes □    
 
 No □  
   
If yes, which one? _______________________________  Monthly premium?  ____________ 
List any other Insurance Plans that you have through an Employer, Retirement, etc. 
Insurance Company  Name:   
 
 
 
 
 
 
 
Hospital/Doctor Coverage     □    
 Prescription Coverage  
□   
 
 
Does you monthly income fall below $2641.00  for Single  
or $3572.00 for Married couple?  Yes □     No □ 
 
What pharmacy do you use? _________________________________  
List your medications on the other side of this form. 
 
Date Rec’d:  
              #  
  

Prescription List 
Drug Name                  Strength                  Dosage per day 
Quantity Ordered per month 
 
Example: Lipitor            10 mg. 
           
    1 
 
 
30 
                Take information from RX container.     Please print clearly. 
 
 
 
 
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