The Hub can help you compare plans and enroll in Medicare Part D prescription coverage.

Medicare Part D Open Enrollment begins October 15th. During this time you can switch from one plan provider to another. The Hub can help you look at your plan options, compare plans, and enroll in the coverage that is best for you.

To get started, fill out the form below about the current medications you take. Doing this will help us find the plan options that will work for you. Once you submit the form, we will review your information and contact you to discuss your options. As a part of the form, you can let us know whether you'd like us to contact you by email or phone, at a time that is convenient for you.

if you have questions while you're filling out the form, you can contact us by phone at 1-866-333-2466.

Note: All information submitted via this form is secure.

Medicare Part D Plan Comparison Request Form

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Representative Information

Representative First Name ^*

Representative Last Name ^*

Representative Email ^*

Hub staff will need permission from the client to discuss their personal health information with you. The Hub staff will discuss options for this when they reach out to you. Provide information below for the person you are completing this form for.

Contact Information and Preferences

First name

Last name

Address

City

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Preferred contact method

Phone

Phone number

Please provide 3 dates and times that will work best for us to contact you.

Date

Time

Date

Time

Date

Time

Medicare and Medication Information

Date of Birth ^*

Prefix or Suffix

Payee Zip Code (if applicable)

Medicare Number/Medicare Beneficiary Identifier

Effective Date Part A^*

Effective Date Part B^*

County of Residence

Do you currently take medications prescribed by a doctor?

Yes

Please complete the medication fields below. Or if you'd like to send a secure email with your medication list attached, check this box.

Prescribed Medications

Medication Name	Medication Strength	Medication Type	Refill Amount	Refill Frequency

Preferred Pharmacy^*

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Prescription Medication Form

Medication Name^*

Generic version?

Medication Strength^*

Extended release?

Medication Type

Refill Amount

Refill Frequency

The Hub can help you compare plans and enroll in Medicare Part D prescription coverage.

Medicare Part D Plan Comparison Request Form

Representative Information

Contact Information and Preferences

Medicare and Medication Information

Prescribed Medications

Prescription Medication Form

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