Medicare Product Analysis Form

Please use Google Chrome or Microsoft Edge to complete this form. If you continue to have issues, reach out to your advisor at NateE@horanassoc.com, HeatherB@horanassoc.com or ChrisM@horanassoc.com.

Company

Salutation

First Name

Preferred First Name

Middle Initial

Last Name

Address

City

State

ZIP

U.S. County

Date of Birth

Phone Number

Is this a cell phone?

Yes

Email is my preferred method of communication

Phone is my preferred method of communication

Preferred Retail Pharmacy

Pharmacy Address

I am interested in using the 90-day mail order option

Medicare Number

Part A Date

Part B Date

Please list all of your prescribed medications, excluding over-the-counter supplements.

Do you take any medications?

Please list all of your prescribed medications, excluding over-the-counter supplements.

Generic	Medications	Dosage (ex. 20 mg)	Frequency (times/day)
Generic	Medications	Dosage (ex. 20 mg)	Frequency (times/day)
Generic	Medications	Dosage (ex. 20 mg)	Frequency (times/day)
Generic	Medications	Dosage (ex. 20 mg)	Frequency (times/day)
Generic	Medications	Dosage (ex. 20 mg)	Frequency (times/day)

Preferred Hospital

Hospital Address

Do you have a preferred doctor?

Please list all of preferred doctors.

Please select your HORAN advisor

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