What is your name as it appears on your Medicare card? What is your Medicare claim number? What is your date of birth? ___ ___/___ ___/___ ___ ___ ___ What is the effective date for your Medicare?Part A __ __/__ __/__ __ __ __ Part B __ __/__ __/__ __ __ __Part A ____________________ Part B ____________________MEDICARE PRESCRIPTION DRUG COVERAGE WORKSHEET

5. What is your address? ___________________________________________________________ City, State, Zip Code _____________________________________________________________ Phone # _________________________________________6. What county do you live in? _________________________7. What prescription medications do you currently take? (Please also list dosage and how many you take in 1 month. PLEASE PRINT CLEARLY DRUG NAMEDOSAGE30-DAY QUANTITY8. What is your preferred pharmacy? ____________________________________________________________

To help determine your eligibility for Extra Help with Medicare Part D costs please answer the next two questions.Single, widowed, divorced or live apart from spouse___ My annual gross income is $17,235 or less___ My annual gross income is greater than $17,235Married___ Our annual gross income is $23,265 or less___ Our annual gross income is greater than $23,265

Liquid assets are the total value of your savings, investments and real estate. Do not include your primary home, vehicles, burial plots or personal possessions.Single, widowed, divorced or live apart from spouse___ My assets are $13,300 or less___ My assets are greater than $13,300Married___ Our assets are $26,580 or less___ Our assets are greater than $26,580

SHICK DisclaimerSHICK Volunteer Name: ____________________________________SHICK Volunteer Telephone: ________________________________I have reviewed at least 3 Medicare Part D Prescription Drug Plans and have chosen the following plan:_________________________________________________________________________________and I give the SHICK volunteer my authorization to enroll me in the above plan using the information I have provided. I confirm that all information provided is truthful and accurate and I confirm that I will not hold the SHICK volunteer responsible for my decision nor will I have the volunteer or the SHICK organization responsible for any liability rising our of assisting me in my enrollment.I understand that I may not change my drug plan until the next open enrollment period which will beOctober 15, 2015 to December 7, 2016I also understand the costs and covered medications quoted on the plan Ive chosen are subject to change.Signature:________________________________ Printed Name: _______________________________Date: ___________________ Drug List ID: ____________________ Password Date: _______________