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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.
  • MM slash DD slash YYYY
  • Example: Lisinopril 20 mg 1 per day
    Rx NamemgDose 
  • Example: Dr. John Doe Cardiology Plantsville 860-123-4567
  • Additional Information

  • Electronic Signature *

    Please type your First and last Name
  • 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.
  • If you have any questions regarding this form, please contact Beacon Retiree Benefits Group LLC at 800-378-2585.
  • This field is for validation purposes and should be left unchanged.