| Please see page 2 of the enrollment application for detailed instructions on completing the forms. |
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- Complete all four sections on Page 3 of the application
- Section 1 - Applicant Information
- Section 2 - Medicare Part D Prescription Drug Plan Information
- Section 3 - Medicare Part D Prescription Drug Expenses
- Section 4 - Household Information
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Sign and date the "Patient Authorization to Release and Disclose Medical Information"
section on Page 4 of the application.
- Enclose a copy of the Medicare Part D Prescription Plan ID card.
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Provide proof of $600 in annual prescription expenses from the most recent PDP
Plan Statement or statement from the local pharmacy.
- Provide proof of income: either a tax return, or social security statement.
- Be sure to print the applicant's name and date of birth on each page submitted.
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