Free Savings Evaluation Fill out this form to receive a free drug savings evaluation and to see if you qualify for assistance with Medicare Part D. Fill out the form below and we will contact you! Your Name: (required) Your Email: (required) Your Phone Number: (required) Your Address: Best Method to Contact You: --EmailCall If you want to know if you qualify for any extra help in paying for your drugs, include your total household income and marital status in the comments section. Your Comments: Current Pharmacy Name: Current Pharmacy Number: Drug Allergies/Type of Reaction: Medication #1: Medication #2: Medication #3: Medication #4: Medication #5: Medication #6: Additional Medications: