THE PAPER OPTION
Your form.
Ready to print.
Prefer to write it down? Open the one-page prescription form, print a copy, and send it back when you’re ready.
Open Printable Form ↗
PDF · 1 page · Opens in a new tab
1. Open and print.
Open the PDF, then select the print icon or choose Print from your browser’s menu. Use letter-size paper (8.5 × 11 inches).
2. Fill in your details.
Include your medications, dosages, pharmacy, and current plan information. Write “NONE” if you don’t take prescriptions. Use another copy if you need more medication rows.
3. Return your completed form.
Email your completed form to partd@ssmforms.com.
Or mail it to:
Saving Seniors Money
1216 Argyll Pl.
Lincoln, NE 68512
Rather complete it online? Start your online form.
A question? A little help?
For questions about the form or problems getting started, email Teven.