PA MEDI Medicare Beneficiary Screening Intake Form Step 1 of 4 25% Beneficiary informationHiddenDate MM slash DD slash YYYY Name First Last Address* PhoneEmail Do you have a MyMedicare Account? Yes No I don't know MyMedicare Username MyMedicare Password Health Insurance InformationCurrent Medicare Coverage Medicare Advantage Prescription Drug Plan New to Medicare Current Plan Company/Name Current 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 PharmacyPharmacyLocationIs this your preferred pharmacy? Yes No I don't know Are you open to using other pharmacies if your prescription costs are lower? Yes No NotesEmailThis field is for validation purposes and should be left unchanged.