Get This Form May Be Sent To Us By Mail Or Fax:

Filling out the 'This Form May Be Sent To Us By Mail Or Fax:' form is essential for requesting Medicare prescription drug coverage determination. This guide provides clear steps to assist you in completing the form accurately and efficiently, ensuring that your request is processed smoothly.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the form and open it for completion. This will allow you to access the necessary document easily.
2. Begin by filling out the enrollee’s information section. This includes the enrollee’s name, date of birth, address, city, state, zip code, and phone number. It's crucial to provide accurate information here.
3. Next, enter the enrollee's Member ID number. This helps to identify the enrollee within the system.
4. If someone other than the enrollee or prescriber is making the request, fill out the requestor’s information section, including their name, relationship to the enrollee, address, and phone number.
5. Attach any representation documentation if the request is made by an individual other than the enrollee or their prescriber. This could be a completed Authorization of Representation Form or a suitable equivalent.
6. Specify the prescription drug you are requesting, including the strength and quantity per month if known. Accurate details ensure that the request is clear.
7. Indicate the type of coverage determination request you are making by selecting the appropriate option that describes your situation.
8. Provide any additional information or attachments that may support your request, particularly if you have documentation from a prescriber.
9. If needed, check the box for expedited decisions, and ensure you have a supporting statement from the prescriber if applicable.
10. Finally, ensure the form is signed and dated by the person requesting the coverage determination, which could be the enrollee, prescriber, or representative.
11. Review all entered information for accuracy. After confirming everything is complete and correct, you can save changes, download a copy, print the form, or share it as needed.

Ensure your request is processed timely by completing the form online now.