Midwest Senior Select, Inc.
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BULLET HOME
BULLET Additional Products & Benefits
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Please provide the following information

Are You Eligible for Medicare?
Do you receive Medicaid assistance?
Estimate Your Monthly Drug Cost
List Your Prescription Drugs and Dosage
Providing a list of your prescriptions drugs and estimated costs is not required and will not affect eligibility for any Medicare Part D Prescription Drug Plan you select. Any information you provide will only be used to help guide you toward appropriate Medicare Part D Prescription Drug Plan(s) for your unique needs. You cannot be declined coverage. Everyone with Medicare, regardless of income, health status, or prescription drug usage, will have access to prescription drug coverage beginning on January 1, 2006.
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Street Address
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Contact Instructions
Midwest Senior Select, Inc.
11518 N. Port Washington Road, Suite 4. Mequon, Wisconsin 53092
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