JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Medicare Annual Enrollment Form-Washburn County 2020
October 15 – December 7 All Information provided is kept confidential.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
First Name
*
Your answer
Last Name
*
Your answer
Address
*
Your answer
City/Town
*
Your answer
County
*
Washburn
Rusk
Barron
Zip Code
*
Your answer
e-mail address if available
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Are you a Veteran?
Yes
No
Clear selection
Are you a disabled?
Yes
No
Clear selection
Medicare Claim Number
*
Your answer
Coverage Start Date Part A (on your red, white & blue Medicare card)
*
MM
/
DD
/
YYYY
Coverage Start Date Part B (on your red, white & blue Medicare card)
*
MM
/
DD
/
YYYY
Do you have a MyMedicare.gov account?
*
Yes
No
If Yes, will you please provide your User Name below
Your answer
If Yes, will you please provide your Password below
Your answer
If No, Can we help you create one?
Yes
No
Clear selection
I give you permission to help me create a User Name and Password
Yes
No
Clear selection
I give you permission to securely store my User Name and Password provided above or newly created.
*
Yes
No
Current Medical Clinic
*
Your answer
Preferred Pharmacy #1
*
Your answer
Preferred Pharmacy #2
Your answer
Preferred Pharmacy #3
Your answer
Do you fill prescriptions by mail order?
*
Yes
No
Complete name of your health insurance plan as printed on your insurance card:
Your answer
Complete name of your Medicare Part D Prescription Drug Plan, as printed on your card
Your answer
Please select one of the following:
*
Please mail my comparison for my review. If I want to make changes or have questions, I will call to set up a telephone or virtual meeting.
Please call me to go over my comparison.
Please call me to schedule a virtual meeting to go over my comparison.
Best phone number
Your answer
Do you have any prescription drugs?
*
Yes
No
Next
Clear form
Never submit passwords through Google Forms.
This form was created inside of Barron Aging and Disability Resource Center.
Report Abuse
Forms
