Online Medicare Sign Up

SCOTT PHARMACY'S ONLINE FORM WILL BE ACTIVE AGAIN IN THE FALL OF 2025.

THANK YOU!!

Section 1: Medicare Beneficiary

Name:*

First NameLast Name

Date of Birth:*

Phone Number:*

Would you like to add a spouse or significant other?*

YesNo

Name of spouse/significant other:*

First NameLast Name

Date of Birth:*

Date

Phone Number:

Please enter a valid phone number.

Preferences on who preforms the Medicare Part D Review:*

MattJennyFirst Available

Are you a current or new Scott Pharmacy patient (New patients will need an up-to-date medication list for the review)?*

Current patientNew patient

How would you like to have the review preformed? *Pharmacy prefers phone.*

*PhoneIn personOther

Will you be gone for vacation/winter months during open enrollment (open enrollment period: October 15th thru December 7th)?*

YesNo

What day will you be leaving?

Section 2: Important information

The pharmacy will start FREE Medicare Open Enrollment reviews to any patients who need a stand-alone Medicare Part D Plan (PDP), October 15th - December 7th. We cannot assist with Medicare Advantage (HMO) plans. Most reviews will be completed during the month of November.

Every year there are big changes within all plans. It is very important to review your plan EVERY YEAR! Our pharmacy will help find you the best plan that meets your needs (free delivery, free mail-outs, Brand discounts, etc.).

After you submit this form, our pharmacy WILL contact you for a review within the open enrollment period. Most calls will occur in November.

Medicare Open Enrollment - 2024