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Nevin and Witt RX Collection

License # OD26864

Please provide as much information as possible and we will be in touch as soon as we can with Part D Plan recomendations.  Please submit one form for each person.  Accuracy is YOUR responsiblity and companies may change their list of covered drugs AFTER you apply.  We are not responsible for these changes....

On Each "Current Prescription" line, please provide:

1) Name of Each Drug and if ER/XR/SR etc.  (Accurate            spelling is important and only drugs that you get a                prescription for - not Over The Counter)

2) Strength (Example - 10mg)

3) Dosage (How Much/Many per Day)


Then Scroll to bottom and "Submit"

Thank you. We will be in touch soon.

Please call us at 1-800-247-9889 with any questions.

ls.jpg is not associated with the Federal Medicare Program.  You can find the Federal Program site at www.Medicare,gov

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