OnlyHealthInsurance’s Prescription Drug Form – 2022 Plan Year For assistance in evaluating Medicare Prescription Drug plan options for 2022, please complete this form thoroughly and submit. After it is received, we will prepare and email you our report and recommendation. We will be happy to answer any questions by email or by phone appointment and assist with enrollment as necessary. Full Name Email Zip Code Current Drug Plan Carrier & Full Plan Name: (i.e. WellCare Value Script )Do you have a pharmacy preference?NoYesPharmacy Name: Email (for receipt) May we commmunicate with you via email regarding your prescriptions?NoYesPrescriptions Please list only the prescription drugs you are currently taking and not medications you are discontinuing or may have used in the past but no longer use. If there is a medication you expect to take but has not yet been prescribed, please include the name so we can check the formulary drug lists of high ranking plans. Generally, over-the-counter medications are not covered under Part D plans. Medication Name(s)Drug Type (Tab, Cap, Drops, Ointment, Lotion, Patch, etc)Dosage (mg, mcg, ml, etc)Quantity (Doses per month, i.e.: 30, 60, 90)For ‘as needed’ medicine, indicate how many prescriptions filled per year, (i.e., 1 x, 3 x, 4 x, etc.)Generic OK? (yes/no) PaymentAnnual Prescription Consulting Fee* Price: Total $0.00 How would you prefer to pay the annual consulting fee?* Mail a Check Pay online with a credit card Once you submit this form, please mail us a check for the $175 consulting fee payable to: OnlyHealthInsurance 936B 7th St. #350 Novato, CA 94945 We will begin preparing our report and recommendation, once the payment is received. Thank you. Credit CardCard Details Cardholder Name NameThis field is for validation purposes and should be left unchanged.