BINNING INSURANCE
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2022 Medicare Part D Annual Enrollment
2022 Medicare Part D Annual Enrollment Form
(Annual enrollment Period 10/15/21 - 12/7/21)
*
Indicates required field
Name
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First
Last
DOB
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Spouse's Name
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First
Last
Spouse's DOB
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Phone Number
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Email
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Address
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Line 1
Line 2
City
State
Zip Code
Country
My current PRESCRIPTION DRUG PLAN is
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My current monthly premium for my DRUG PLAN
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Spouse's DRUG plan (if applicable)
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Spouse's monthly PRESCRIPTION DRUG PLAN premium
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Please list all Medication, Dosage (tab or cap) and the Quantity per day:
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(If you are on Inhalers, Ointments and Creams please list on your sheet how often you fill EACH of them. If you take Insulin please note how many pens per month.)
Will you consider an alternative/generic drug for brand name?
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Yes
No
Please list 2-3 preferred pharmacies you WILL go to
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Would you consider mail order if it saved you money?
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Yes
No
Please send me information of Dental Insurance:
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Yes
No
My current Dentist is
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Address
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Line 1
Line 2
City
State
Zip Code
Country
As always, your referrals are very much appreciated. If you know of someone who might benefit from ANY of our services, please complete the following information:
Referral Name
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First
Last
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Referral Email
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Referral Address
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Line 1
Line 2
City
State
Zip Code
Country
Questions?
Call Maureen at 608-234-1521 or Martin at 608-669-5767.
Thank you for choosing Binning Insurance!
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Home
What We Do
A,B,C,D's of Medicare
Who We Are
Contact
Media
2022 Medicare Part D Annual Enrollment