MEDICARE PART D PDP ENROLLMENT ASSISTANCE FORM
MEDICARE PART D PDP ENROLLMENT ASSISTANCE FORM
|Applicant Name: |
| |
|Telephone Number |Social Security Number: |
| : | |
| |Please choose one: |
|1) | | |
| | |If I am determined eligible for PAAD, please ENROLL me in a Medicare Part D |
| | |plan for which PAAD will pay the premiums. I have listed my medications below. |
|2) | | |
| | |If I am determined eligible for PAAD, please DO NOT switch my current |
| | |Medicare Part D Plan. I will be responsible for the premiums. |
|3) | |I am enrolled in a Medicare Advantage plan with prescription coverage. |
|4) | | |
| | |I have prescription coverage through a retiree or union health plan, |
| | |which has notified me NOT to enroll in a Medicare prescription drug plan. |
| | |I am enclosing a copy of the notification. |
| | I CURRENTLY DO NOT TAKE ANY PRESCRIPTION DRUGS. |
|List the name of the pharmacy you use: |
| |Drug Name |Strength |Quantity |
|1. | | | |
|2. | | | |
|3. | | | |
|4. | | | |
|5. | | | |
|6. | | | |
|7. | | | |
|8. | | | |
|9. | | | |
|10. | | | |
If you need to provide additional information, please attach a piece of paper with your name,
Social Security number, and additional drug names, strength, and quantity. Thank you.
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