AAA

Medicare Plan Comparison Form


Please complete all applicable information. Items marked with asterisk (*) are required. 













Medicare Information

Insurance Company and Plan Name or Letter
What plans do you have in addition to your Medicare?
Ex: Viva Medicare Plus HMO, Blue Advantage PPO, Humana Plan G, Silver Script Choice PDP, Federal Blue Cross, PEEHIP Humana, CHAMPVA




Income/Subsidy Information



Other Information



Page 2

List Current Prescription Medications

You may have a printed list from your pharmacist, or an additional sheet attached.
Please do not include Over the Counter (OTC) Medication.


Here's an example: Lipitor 10mg.


How often do you take this medication?


In-Person Appointments will be held at UWCA Spain Community Chest Building, 3600 8th Ave. South, Birmingham, AL. 35222.

Appointments are thirty minutes per client. Same-day in-person appointments are not available. 

Please call 205-458-3330 for appointment information, changes, or cancellations.