APPRISE Medicare Beneficiary Screening Intake Form Step 1 of 4 25% Beneficiary informationName First Last PhoneZip CodeDo you have a MyMedicare Account? Yes No I don't know MyMedicare UsernameMyMedicare PasswordHealth Insurance InformationCurrent Medicare Coverage Medicare Advantage Prescription Drug Plan Current Plan Company/NameCurrent Monthly PremiumFinancial Assistance InformationDo you have PACE or PACENET? Yes No I don't know Do you have Extra Help? Yes No I don't know Do you have Medicaid? Yes No I don't know Current Medical ProvidersPrimary Care InformationPrimary Care ProviderPractice Name & LocationSpecialist InformationSpecialistPractice Name & Location Click the "+" to add another Specialist(up to 5)Hospital InformationHospitalLocation Click the "+" to add another Hospital(up to 2)Other Providers (Example: DME)ProviderAddress Click the "+" to add another Provider(up to 2) List of Current MedicationsCurrent MedicationsMedication NameDoasgeFrequencyType (Brand or Generic) Click the "+" to add another Medication(up to 15) Pharmacy InformationCurrent PharmacyPharmacyLocationWould you consider using another pharmacy if your prescription costs are lower? Yes No Would you consider using mail order? Yes No Would you consider using mail order? Yes No NotesCommentsThis field is for validation purposes and should be left unchanged.