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  • Medicare Part D Direct Member Claim Form

Get Medicare Part D Direct Member Claim Form

Medicare Part D Coordination of Benefits / Direct Claim Form See the back for instructions. Complete all information. An incomplete form may delay your reimbursement. If you are not a Medicare Part D member and complete this form it may delay the processing of your claim. Member/Subscriber Information See your prescription drug ID card.

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Form CMS-1696 can be downloaded at .cms.gov or obtained by calling the Customer Service number on your member ID card. The claim may be submitted via mail or fax to the address or phone number on the Medicare Part D Prescription Drug Claim Form.

This notice has information about your current prescription drug coverage with your employer and about your options under Medicare's prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan.

Proof can include your Medicaid card and an award letter from the Social Security Administration (SSA), or your yellow auto-enrollment letter from Medicare.

Part D is provided only through private insurance companies that have contracts with the federal government—it is never provided directly by the government (unlike Original Medicare).

Enrollment in Medicare Part D plans is voluntary, except for beneficiaries who are eligible for both Medicare and Medicaid and certain other low-income beneficiaries who are automatically enrolled in a PDP if they do not choose a plan on their own.

Checking Part D Is Easy and Simple Conveniently, one can go online to Medicare.gov to check eligibility and status in any part of Medicare.

Use this form to request reimbursement for covered medications purchased at retail cost.

If you are enrolled in a Part D plan (Medicare prescription drug benefit), you will use the Part D plan's card at the pharmacy. If you are enrolled in a Medicare Advantage Plan (like an HMO, PPO, or PFFS), you will not use the red, white, and blue card when you go to the doctor or hospital.

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© Copyright 1997-2025
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232