Healthcare Provider & Prescription Drug Information

Start by keeping track of your individual healthcare coverage needs. Providing correct and complete information about your healthcare providers and prescription drugs will help your benefits counselor analyze your coverage needs.

Please download and complete the Healthcare Provider & Prescription Drug form. Fax or mail the completed form to us 10-14 days prior to your scheduled consultation. Doing so will shorten the amount of time you spend on the consultation call as your information will be preloaded and available to your benefits counselor. Please complete one form per person.

Download the form