Medication List

Glidden Group Health Insurance
402 W Canfield Ave. Coeur d Alene, Idaho 83815
PHONE: 208-640-3787
MEDICATION LIST
PLEASE PROVIDE AN UPDATED, ACCURATE AND COMPLETE LIST OF ALL YOUR MEDICATIONS.
By completing this form, you are authorizing Glidden Group Health Insurance to analyze your prescription drug utilization and are requesting a recommendation for your Part D Prescription drug coverage or Medicare advantage plan and authorizing to receive a call and/or an email regarding my Prescription drug coverage options.
I understand that I am volunteering this prescription medication information to evaluate my prescription drug coverage options. This information is completely confidential.
*Type your Name here *
First Name Middle Name Last Name Suffix (Jr, Sr, III, ect)
Client Gender *
Client Birth Date *
Month Day Year
Client E-Mail *

Confirmation Email Confirm E-mail
Client Phone Number *
Primary Care Physician
First Last
Do you have any health concerns that we should know about for the 2023 year?
Patient Medications
Be sure to include all medications, over-the-counter, diabetic, dietary supplements and vitamins.

Please List All Medications

Patient Medications