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(800) 295-5860

6638 W. Ottawa Ave, #120

Littleton, Colorado

info@hbsltc.com

www.medicarehbs.com

How to Get Started

To request your Medicare Planning Options Analysis, please complete the 3-step form on this page. Please be advised if you leave the page before finishing the final step, your progress will not be saved.
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Medications

Medication Information Sheet

Please complete and submit the form below.

    Medication Sheet

    Please Complete the Following:
    Name:
    Email:
    Medications- We must know exact information to get an accurate drug analysis
    Drug Name
    Mg/Mcg
    Form
    #/day
    How Often Refilled
    Generic OK?
    Drug Name
    Mg/Mcg
    Form
    #/day
    How Often Refilled
    Generic OK?
    Drug Name
    Mg/Mcg
    Form
    #/day
    How Often Refilled
    Generic OK?
    Drug Name
    Mg/Mcg
    Form
    #/day
    How Often Refilled
    Generic OK?
    Drug Name
    Mg/Mcg
    Form
    #/day
    How Often Refilled
    Generic OK?
    Drug Name
    Mg/Mcg
    Form
    #/day
    How Often Refilled
    Generic OK?
    Drug Name
    Mg/Mcg
    Form
    #/day
    How Often Refilled
    Generic OK?
    Drug Name
    Mg/Mcg
    Form
    #/day
    How Often Refilled
    Generic OK?
    Drug Name
    Mg/Mcg
    Form
    #/day
    How Often Refilled
    Generic OK?
    Drug Name
    Mg/Mcg
    Form
    #/day
    How Often Refilled
    Generic OK?
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