Get Big Sky Rx Program Application - Dphhs Home - Dphhs Mt

Filling out the Big Sky Rx Program Application can be a straightforward process when you understand each section and the required information. This guide provides step-by-step instructions to help you complete the application accurately and effectively.

Follow the steps to complete your application successfully.

1. Click the ‘Get Form’ button to access the Big Sky Rx Program Application form.
2. Begin by providing your personal details in the 'Applicant' section. This includes your first name, middle initial, last name, suffix, Social Security number, Medicare number, and date of birth. Make sure to fill these fields accurately.
3. If applicable, complete the 'Spouse' section with your spouse's information, including their first name, middle initial, last name, suffix, Social Security number, Medicare number, and date of birth.
4. In the 'Address' section, provide your mailing address, including street or P.O. Box number, city, and zip code. Additionally, fill out your home phone number.
5. If you have an alternate address, complete the 'Alternate Address' section with the relevant details and the duration of your stay there.
6. If you would like to provide additional contact information for someone else, fill out the 'Additional Contact' section with their name, mailing address, and phone number.
7. You will need to indicate if you or your spouse is a member of a tribe, as well as if you have received Medicaid benefits in the past 12 months.
8. Next, indicate the number of additional family members living with you who depend on you for financial support.
9. Report your monthly family income by filling in the gross monthly income for each family member who earns income. Specify each income source and provide the amounts accordingly.
10. In the 'Other Unearned Income' section, list any additional monthly incomes such as pensions or benefits.
11. If you expect to earn wages this year, report your anticipated earnings in the 'Earned/Wages Incomes' section.
12. Provide information regarding any work-related disability or blindness expenses incurred by you or your spouse.
13. In the 'Family Assets' section, indicate your total family assets, which may affect your eligibility for Social Security Extra Help.
14. If you have applied for Social Security Extra Help, complete that section and attach the determination copy.
15. Indicate whether you are enrolled in a Medicare prescription drug plan, providing the plan name and other relevant details.
16. Select your preferred payment method for Big Sky Rx benefits and check the appropriate boxes according to your preference.
17. Finally, review the declaration of understanding and sign the application. If applying jointly, your spouse must also sign.
18. After completing the form, you can save changes, download, print, or share it as needed.

Complete your application online today to benefit from the Big Sky Rx Program!