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your medications?

If you are providing this information on behalf of another person, please fill out the information for that person. Your contact information will be requested at the end.

Patient Information
First Name:
Middle Initial:
Last Name:
Gender:
 Male    Female   
Birthday:
 /   /   MM/DD/YYYY
Which State do you live in?
Are you a US Citizen?
 YES    NO   
   Do you have a green card?
 YES    NO   
Are you enrolled in Medicare?
 YES    NO   
   Are you enrolled in Medicare Part D?
 YES    NO   
   Are you in the gap or donut hole?
 YES    NO    Not Yet   
Do you have any prescription insurance for your medications?
 YES    NO   
Please select one of the following statements regarding your insurance coverage:
 I have no prescription insurance coverage.
 I have coverage for some but not all of my medications.
 I have prescription insurance for all medications but the co-payments or deductible are not affordable.
 I have prescription insurance coverage but have hit the limit of coverage for the year.
 None of the above.
How many people live in your household? 
 1
 2
 3
 4
 5+ 
Please list the approximate total monthly income for everyone in your household (rounded to the nearest dollar):
$
Please enter a valid dollar value
Example: "1156"
Did you file a Federal tax return (Form 1040 or similar) for either of the last 2 years?
 YES    NO   
Current medications?
(not required)
Did you complete this form for yourself or for someone else?
 Self 
 Someone Else 
Who should Med Advocates contact to follow up on this application?
First Name:
Last Name:
Relationship to Applicant
 Spouse
 Parent, Child, or Sibling
 Not Related
 Medical Power of Attorney
 Other
Phone Number "xxx-xxx-xxxx":
Best Time to Contact Me:
My Time Zone:
Enter e-mail address:
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I do not have an email address
How did you hear about Med Advocates?
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