HOMEMEDICARE & RXINDVIDUALDENTAL EDUCATIONCONTACTNEEDS ASSESSMENT

 1-845-773-9164
Simple Solutions

PALMITER BUSINESS SOLUTIONS INC
           ...Healthcare solutions for Hudson Valley Seniors
Name
Please list any prescription medications, dosage & frequency.   
Please list your current medical providers, their specialty and location. 
All information is private and will only be shared with your selected agent. If you are unable to answer leave the question blank.  
Welcome!  Please fill out the form below to help us assess your personal health plan needs.  
What is your preferred pharmacy?
County 
Do you have Original Medicare? 
Contact Info
What is your current health plan? 
Do you give permission for us to contact you? 
Are you Medicaid eligible? 
Anything else we should know? 
Phone Number
Email
​Is this an employer group plan? 
What are you mostly interested in?
*
Agent you are working with:
Date of Birth
Example:  Losartan Potasium 50mg 1 x Daily
Example:  Dr. John Smith, Kingston, NY - Primary Care
Medicare Part B
Medicare Part A
Email
Yes
Phone
Medicare Advantage Plans
Medicare Supplement (Medigap) plans
Part D (Prescription) Plans
Not sure
No
Yes
No