Information Request - NYS of Health plans

Information Request for KBellbenefits, LLC

Name (only one person per information request form please):

COMPLETE Address (Street, City, State, Zip, & County):

Preferred Phone (Area Code & Phone Number):

Email:

When would you like your medical plan to start or change? Click calendar icon.

OPTIONAL: Upload a document listing ALL your physicans

Upload File

Upload supported file (Max 15MB)

Primary Care Physician

List their specialty:

1 - DDS:

1 - List their specialty:

2 - Doctor:

2 - List their specialty:

3 - Doctor:

3 - List their specialty:

4 - Doctor:

4 - List their specialty:

5 - Doctor:

5 - List their specialty:

6 - Doctor:

6 - List their specialty:

7 - Doctor:

7 - List their specialty:

8 - Doctor:

8 - List their specialty:

List additional physicians and their specialty in the text field below

Your preferred pharmacy name and location:

OPTIONAL: Upload a document listing ALL of your prescription medications.

Upload File

Upload supported file (Max 15MB)

1 - Drug name - enter NONE if no Rx

1 - Dose (mg, tab, ml, etc)

1 - How often?

2 - Drug name

2 - Dose (mg, tab, ml, etc)

2 - How often?

3 - Drug name

3 - Dose (mg, tab, ml, etc)

3 - How often?

4 - Drug name

4 - Dose (mg, tab, ml, etc)

4 - How often?

5 - Drug name

5 - Dose (mg, tab, ml, etc)

5 - How often?

6 - Drug name

6 - Dose (mg, tab, ml, etc)

6 - How often?

7 - Drug name

7 - Dose (mg, tab, ml, etc)

7 - How often?

8 - Drug name

8 - Dose (mg, tab, ml, etc)

8 - How often?

9 - Drug name

9 -Dose (mg, tab, ml, etc)

9 - How often?

List additional drugs, dose, and frequency of intake in the text field below

Additional comments and if your have Medicaid, enter your ID number below:

Thanks for submitting!

Please visit:www.kbellbenefits.com