Your Rx Medications - Karla's Health Care Insurance

Please fill out the form below and submit it, doing so will help Karla process your application.

Name *

First

Last

Email *

Phone Number

Zip Code *

Preferred Pharmacy

Do You Use Mail Order?

Do You Order Monthly or Every 90 Days?

Monthly
Every 90 Days

Are You Eligible For Extra Help (Limited Income Subsidy)?

You are eligible for Extra Help if:
– You have Medicare Part A (Hospital Insurance) and/or Medicare Part B (Medical Insurance) AND:
– You live in one of the 50 states or District of Columbia
– If you are married your combined savings, investments and real estate are not worth over $33,240, OR $16,660 if you are not married or not currently living with your spouse.

Prescriptions: Drug Name

Dosage

Times per Day

Drug 2 Name

Drug 2 Dosage

Drug 2 Times Per Day

Drug 3 Name

Drug 3 Dosage

Drug 3 Times Per Day

Drug 4 Name

Drug 4 Dosage

Drug 4 Times Per Day

Drug 5 Name

Drug 5 Dosage

Drug 5 Times Per Day

Drug 6 Name

Drug 6 Dosage

Drug 6 Times Per Day

Drug 7 Name

Drug 7 Dosage

Drug 7 Times Per Day

Drug 8 Name

Drug 8 Dosage

Drug 8 Times Per Day

Drug 9 Name

Drug 9 Dosage

Drug 9 Times Per Day

Drug 10 Name

Drug 10 Dosage

Drug 10 Times Per Day

Doctors: First Name

Last Name

Specialty

Doctor 2 First Name

Doctor 2 Last Name

Doctor 2 Specialty

Doctor 3 Specialty

Doctor 3 Last Name

Doctor 3 Specialty

Doctor 4 First Name

Doctor 4 Last Name

Doctor 4 Specialty

Doctor 5 First Name

Doctor 5 Last Name

Doctor 5 Specialty

Doctor 6 First Name

Doctor 6 Last Name

Doctor 6 Specialty

Doctor 7 First Name

Doctor 7 Last Name

Doctor 7 Specialty

Doctor 8 First Name

Doctor 8 Last Name

Doctor 8 Specialty