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Health Medicare Renewal Questionnaire
Marshall Tague
2023-09-12T12:58:01-07:00
Stewardship Medicare Renewal Questionnaire
Filling out this form helps us make sure you have the
right
plan in 2024.
Name
(Required)
First
Last
Email
(Required)
Please use the same email you use when working with Stewardship.
Medicare Plan Type
(Required)
Stand Alone PDP (prescription/medication)
Advantage Plan
Prescriptions and Medications
(Required)
List all prescriptions and medications (generic name if available) you are taking along with the dosages for each. If none put "none".
Doctor Name(s)
(Required)
List all doctor first and last names that you are currently seeing and would like to continue to see in 2024. If none put "none".
What is your preferred pharmacy?
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