Getting Ready for Open Enrollment:

Make Sure you are ready!

Here is everything you will need:

^_NAME:

^{_{DATE OF BIRTH:}}

^_ADDRESS:

^{_{ZIP CODE:}}

^_COUNTY:

^_PHONE:

^_EMAIL:

^{_{MEDICARE NUMBER: PART A DATE: PART B DATE:}}

^{_{MEDICAID NUMBER(IF APPLICABLE):}}

^{_{CURRENT PLAN:}}

^{_{CURRENT PRIMARY DOCTOR:}}

^_DENTIST:

^{_{CURRENT PRESCRIPTIONS:}}

^{_{DOSAGE AMOUNT:}}

^{_{FREQUENCY: 30 DAYS 90 DAYS 120 DAYS}}

^{_{PREFERRED PHARMACY:}}

^{_{ARE YOU ENROLLED IN EXTRA HELP? (LIS):}}