Doctor and Prescription Form

Name * Required

Email * Required

Zip Code

Physician Name and Location

Please provide an address for each physician to ensure doctors are within network. For example:
1. Dr. John Smith: 80th and Wadsworth
2. Dr. Jane Smith: University and Quebec

Prescription Name/Dose/Frequency

Please list each prescription you take
For example:
1. Atorvastatin 10mg 2x/day
2. Levothyroxine 10mg 1x/day

**By completing the form above, I understand that my licensed sales agent may call or email me to discuss Medicare Advantage, Prescription Drug Plans, and Medicare Supplement Insurance.** * Required

ReDiscover Insurance is an independent licensed insurance agency and is not affiliated with or endorsed by the government or the federal Medicare program. Insurance-related solicitation. We do not offer every plan available in your area. Currently we represent 8 organizations which offer 1-100 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all your options.

This is a solicitation for insurance.
Calls are for marketing purposes.
Cellular carrier charges may apply.
Providing permission does not impact eligibility to enroll or the provision of services.
You can change permission preferences at any time by contacting 720-722-0589.