Pharmacy Home Delivery

P.O. Box 668
Roswell, GA 30077

Customer Service: (800) 862-1456
Toll Free Fax: (888) 805-2406

Free Savings Evaluation

Fill out this form to receive a free drug
savings evaluation and to see if you qualify
for assistance with Medicare Part D.

Your Information
* Name
* Email
* Confirm Email
Phone
Address
Address Cont.
City
State, Zip

If you want to know if you qualify for any extra help
in paying for your drugs, include your total household
income and marital status in the comments section.

Your Comments

Insurance Information

Medicare: Yes No

Medicaid: Yes No

Private Ins.: Yes No

Drug Card: Yes No

Copays:

$ Generic

$ Brand

$ Non-Form.

Diabetic: Yes No

Brand of Meter:

Drug Details

Name of Drug	Drug Strength (mg)	Pills/ Day	Your Cost 30 Days Supply	Is Your Cost a Co-pay
				Yes	No
				Yes	No
				Yes	No
				Yes	No
				Yes	No
				Yes	No
				Yes	No
				Yes	No
				Yes	No
				Yes	No
				Yes	No
				Yes	No
				Yes	No
				Yes	No
				Yes	No
				Yes	No
				Yes	No
				Yes	No
				Yes	No
				Yes	No

Note: If more than 20 drugs, please send second form.