(If you do not have a Medicare ID card please enter the date you will become eligible)
(If you do not have a Medicare ID card please enter the date you will become eligible)
(IF YOU DO NOT HAVE YOUR MEDICARE ID NUMBER YET, PLEASE ENTER ‘UNKNOWN')
Include the following information for EACH
1. Medication Name (copy off pharmacy label)
2. Date Originally Prescribed or Taken
3. Dosage
4. Frequency
5. Diagnosis And/Or Condition
(If you don't have or don't know your policy number please enter "Unknown")
Must be no later than the 28th of the month
