Prescription Drug & Provider Questionnaire

The information requested in the form below will allow our team of specialists to review your current plan along with other plan options and present you with the necessary information to make a plan selection. If you are submitting this form during the Annual Election Period, please note that all enrollments must be completed by December 7th unless you qualify for another election period.

Please note, when you submit this form, one of our Licensed Insurance Specialists (agents) at VibrantUSA will contact you. No obligations to enroll and our services are always free to you.

Name*
First Last
Email*
Phone
Date of Birth*
MM slash DD slash YYYY
State*
County*
County*
County*
County*
County*
County*
Current Insurance Plan
Preferred Pharmacy
Do You Use Mail Order?
- Yes
- No
Prescriptions
RX Name Strength Dosage Refill Quantity Refill Frequency Generic OK?

RX Name: Name of the medicine
Strength: Amount of the active ingredient (example: "150mg")
Dosage: Amount to be taken (example: "2 tablets")
Refill Quantity: Quantity in each refill (example: "30")
Refill Frequency: How often the prescription is refilled (example: "1 month")
Generic OK?: Generic substitutions are OK (example: "yes")
Primary Care Physician
Clinic Name
Specialists
Name Phone # Specialty
Preferred Hospitals
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Email
This field is for validation purposes and should be left unchanged.

** Please note that a sales agent may contact you by one of the methods indicated below as a result of completing this information.

RX Name	Strength	Dosage	Refill Quantity	Refill Frequency	Generic OK?

Name	Phone #	Specialty