Medicare Part D Plan Review Patient Information

After you complete your patient information you will be taken to the scheduling page.

Thanks!

First Name *

Last Name *

Mobile Phone Number
(home number if no mobile number) *

Email Address *

Confirm Email Address *

Date of Birth
(format is MM/DD/YYYY - use slashes) * +

Are you a current patient of Marcrom's Pharmacy? (If completing for a couple ONLY answer YES if BOTH members of the couple are current patients.)
CURRENT PATIENT = having your regular meds filled here in the past 6 months. *

Yes

Do you plan to transfer your medications to Marcrom's Pharmacy? (If for a couple, do both plan to transfer their medications to Marcrom's?) *

Yes

If you do not plan to transfer your medications to Marcrom's Pharmacy we simply can't take a spot for a Medicare Part D review from one of our patients at this time.

However, we do plan on offering this service in the future.

If you come for your review and we are unable to find anything that works for you we do not expect you to transfer your medications.

Please know that we will do the best job for you possible BUT at this time we are only showing what plans would be best for you at Marcrom's Pharmacy. In the future we are working on ways to help no matter what pharmacy you use. We currently have limited staff and therefore time so we have to focus on our patients until that changes.

If we absolutely cannot find a plan that works for you at Marcrom's Pharmacy we might be able to point you in the right direction.

If your intention is to NOT transfer to Marcrom's Pharmacy then the appointment will likely not be valuable to you. *

I understand and agree to the above statement.

Please list your current medications: *

What is your current plan? *

Is your plan an "Advantage" plan or traditional medicare with Part D coverage? *

Advantage Plan

Traditional and Part D

Not sure

NOTE: Please know that if you show up and have an Advantage Plan we will NOT be able to help you choose your plan because it involves your Medical Insurance and not just your drug coverage. We are currently undergoing training to be able to help with this in the future.

STOP

Please do NOT continue.

If you show up and have an Advantage Plan we will NOT be able to help you choose your plan because it involves your Medical Insurance and not just your drug coverage. We are currently undergoing training to be able to help with this in the future.

Todays Date *

Is this meeting for a couple? *

Yes

Please only schedule ONE appointment if you are scheduling for a couple. Our system alots extra time when scheduling for two people. Only ONE appointment is necessary if you answered yes to the question above.

Information for Second Person

First Name: *

Last Name: *

Date of Birth (Person 2)
(format is MM/DD/YYYY - use slashes) * +

What is your current plan (person 2)? *

Please list your current medications (person 2): *

Is there anything else we need to know about your medication or your current plan?

Would you like to receive your Flu Shot when you come for your Medicare Part D review? *

Yes

Will you bring a list of all of your current medications? (Sometimes we know that patients are forced by their insurance to get other medications elsewhere.) *

Yes

By submitting this form I am agreeing to receive texts and/or emails from Marcrom's Pharmacy. *

I agree