Please complete as much of this form to the best of your knowledge. We will contact you to discuss any further information required. This information will be kept and protected for the sole and confidential use of Griset Medicare Solutions.

Tell Us About Your Medicare Coverage:
Current Health Plan:

Premium/Mo: $

Group Plan:
Current Drug Plan:

Premium/Mo: $

Group Plan:
Current Dental Plan:

Premium/Mo: $

Group Plan:
Current Vision Plan:

Premium/Mo: $

Group Plan:
Your effective dates of Medicare Parts A and/or B: Effective Date of Part A
Effective Date of Part B
YOUR CURRENT MAINTENANCE MEDICATIONS:
Drug Name (e.g., Lipitor) Strength (e.g., 250 mg) Dosage (e.g., 1/day)