| Please click here to display the application. For detailed instructions on completing the application, please see Page 2 of the application. |
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| 1. Complete all four sections on Page 3 of the application |
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Section 1 – Applicant Information |
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Section 2 – Medicare Part D Prescription Drug Plan Information |
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Section 3 – Medicare Part D Prescription Drug Expenses |
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Section 4 – Household Information |
| 2. |
Sign and date the "Patient Authorization to Release and Disclose Medical Information" section on Page 4 of the application. |
| 3. |
Enclose a copy of the Medicare Part D Prescription Plan ID card. |
| 4. |
Provide proof of $600 in annual prescription expenses from the most recent PDP Plan Statement or statement from the local pharmacy. |
| 5. |
Provide proof of income: either a tax return, or social security statement. |
| 6. |
If applicable, provide a copy of Low Income Subsidy Notice of Denial. |
| 7. |
Be sure to print the applicant’s name and date of birth on each page submitted. |
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