Rx Drug Form | Otis L McQueen Financial Solutions

NEED ASSISTANCE WITH YOUR PRESCRIPTION DRUG PLANS?

We can help!

Simply provide your information below and Otis will contact you to help you get started on saving money on your prescription drug plan:

Tell Us About Your Rx Prescriptions & Providers

First Name

Last Name

Your Email

Your Phone Number

Zip Code

What is your preferred pharmacy?

Are you open to having your prescriptions mailed to you, if it saves you additional money?

Yes No

Medications fields. Please list your medications and dosages, in the boxes below. One medication per box.

Drug Name (Medication #1)

Dosage

Times per day

Drug Name (Medication #2)

Dosage

Times per day

Drug Name (Medication #3)

Dosage

Times per day

Drug Name (Medication #4)

Dosage

Times per day

Drug Name (Medication #5)

Dosage

Times per day

Your Provider's Name (1st Provider)

Providers Street Address

Address Line 2

City

State

Zip

Your Providers Name (2nd Provider)

2nd Providers Street Address

Address Line 2

City

State

Zip

Your Providers Name (3rd Provider)

3rd Providers Street Address

Address Line 2

City

State

Zip

Comments / Additional Drugs or Doctors

Your information will not be shared. By completing this form you agree that a licensed insurance agent may contact you by phone or email to answer any questions you have regarding Medicare plans. This is a solicitation for insurance.

If you are a human, ignore this field