Medicare Part D Questionnaire

Please fill out the following form and click "Submit" or you may download the document here, which can be filled out on your computer, then printed and mailed to us.

Medicare Part D Questionnaire

Name:
Phone #:
Medicare:	Part A Yes No Part B Yes No
Current Drug Plan is with
Current Medicare Supplement Plan is with:
Medications Taken (Drug Name, Dose & Frequency):
Spouse Medications Taken (Drug Name, Dose & Frequency):
Your E-mail Address:
Date of Birth:
Questions/Comments/Requests:

Castell Insurance
426 E. Washington Street
PO Box 1929
Sequim, WA 98382
Telephone:	360-683-9284
Toll-Free:	800-279-2937
info@CastellInsurance.com