Provider/Drug Information Form Please complete the information below to the best of your ability. The information provided by you is necessary to determining which plan will best meet your needs in the upcoming plan year. As you are aware, this information is critical in ensuring that your doctors participate in the plan of your choosing (if you are enrolling in a Medicare Advantage plan) and that your prescription drugs are reviewed properly.Name* Date of Birth* MM slash DD slash YYYY Phone*Zip* Email* Your Prescriptions Example: Lisinopril 20 mg 1 per day Rx NamemgDose What local Retails Pharmacy do you utilize most? Your Providers Example: Dr. John Doe Cardiology Plantsville 860-123-4567 NameSpecialtyTownPhone Additional InformationDo you have a Grey Connect Card? If so what is your Client Number? Please select which you are currently enrolled in: QMD Medicaid Medicare Saving Program Low Income Subsidy What plan(s) are you currently enrolled in? Have you reviewed your ANOC (Annual Noticed of Change) from your current carrier? Yes No Notes: (anything you want or need us to know to help us review your options for next year)Electronic Signature *Please type your First and last NameMember Signature* Date* MM slash DD slash YYYY * TERMS OF ACCEPTANCE and SIGNATURE I, the applicant for this Provider Drug Form, warrant the truthfulness of the information provided in this application.Terms of Acceptance* I understand that checking this box consitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.*If you have any questions regarding this form, please contact Beacon Retiree Benefits Group LLC at 800-378-2585.EmailThis field is for validation purposes and should be left unchanged. Δ
