PLEASE COMPLETE THE ONLINE FORM BELOW AND CLICK SUBMIT AT THE BOTTOM OF THIS PAGE.

If you prefer to download a PDF copy of this form and Fax or Email it to us, please click the button below. (DO NOT click this button if you intend to complete the online form below!)

MEDICARE Rx UPDATE (PDF Download)

Thank you for updating your Medicare covered Prescription drug list for the upcoming plan year!


Please use the following form to change the dosage or frequency of an existing medication or to provide the name, dosage, frequency and type of a new medication.


If you have additional changes to be made, please click submit and you'll be redirected to a new blank form where you can make the remaining changes.


If your contact information has changed, please contact our office so that we may update our records.


Thank you,

Justin Doherty

Do you receive assistance with your Rx costs?*
Would you be interested in using a Mail Order Pharmacy service?*
Please list your Medications and all applicable information.*
Type of change #1
(Please include any additional letters or abbreviations such as Metoptrolol TAR or Metoprolol SUC)
(Please list the number of pills, tubes, bottles, vials, pens, boxes, etc. that you receive every time you refill a medication. For example, 1 box of 5 pens of insulin or 30 Tables, or 2 tubes, etc)
How long does each refill last? #1
(ie: 30 oz tube, or 18 gram inhaler, or 5 ml bottle, etc)
Type of change #2
(Please include any additional letters or abbreviations such as Metoptrolol TAR or Metoprolol SUC)
(Please list the number of pills, tubes, bottles, vials, pens, boxes, etc. that you receive every time you refill a medication. For example, 1 box of 5 pens of insulin or 30 Tables, or 2 tubes, etc)
How long does each refill last? #2
(ie: 30 oz tube, or 18 gram inhaler, or 5 ml bottle, etc)
Type of change #3
(Please include any additional letters or abbreviations such as Metoptrolol TAR or Metoprolol SUC)
(Please list the number of pills, tubes, bottles, vials, pens, boxes, etc. that you receive every time you refill a medication. For example, 1 box of 5 pens of insulin or 30 Tables, or 2 tubes, etc)
How long does each refill last? #3
(ie: 30 oz tube, or 18 gram inhaler, or 5 ml bottle, etc)
Type of change #4
(Please include any additional letters or abbreviations such as Metoptrolol TAR or Metoprolol SUC)
(Please list the number of pills, tubes, bottles, vials, pens, boxes, etc. that you receive every time you refill a medication. For example, 1 box of 5 pens of insulin or 30 Tables, or 2 tubes, etc)
How long does each refill last? #4
(ie: 30 oz tube, or 18 gram inhaler, or 5 ml bottle, etc)
Type of change #5
(Please include any additional letters or abbreviations such as Metoptrolol TAR or Metoprolol SUC)
(Please list the number of pills, tubes, bottles, vials, pens, boxes, etc. that you receive every time you refill a medication. For example, 1 box of 5 pens of insulin or 30 Tables, or 2 tubes, etc)
How long does each refill last? #5
(ie: 30 oz tube, or 18 gram inhaler, or 5 ml bottle, etc)
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