Get Application For Medicare Savings Program - Formsingov - Benefitscheckup

This guide provides clear and supportive instructions for filling out the Application For Medicare Savings Program, also known as State Form 49228, online. By following the steps below, users will be better prepared to complete the application process smoothly and accurately.

Follow the steps to successfully complete the application.

1. Press the ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out section 1, which asks for personal information about all household members who have Medicare Part A. Ensure to place a 9 in the last column next to the names of individuals applying for benefits.
3. In section 2, provide your current address and telephone number. If there's a different mailing address, include that information as well.
4. Section 3 requires you to confirm whether all applicants are residents of Indiana.
5. In section 4, indicate if any applicant has a court-appointed legal guardian and provide their name.
6. Sections 5 and 6 ask for information about household income. Place a 9 beside all applicable income sources and indicate whether the income has changed in the past three months.
7. In section 7, confirm whether anyone in the household owns life insurance, and do the same in section 8 for car or vehicle ownership.
8. Section 9 requests information on various resources owned by applicants. Place a 9 beside each type that applies.
9. In section 10, provide details about the applicants’ Medicare coverage, including the Medicare number and effective dates for Parts A and B.
10. Answer questions about other health insurance in section 11 and child support in section 12.
11. In section 13, certify the information by signing and dating the form. If someone else is signing on behalf of the applicant, ensure to include the Authorized Representative form.
12. Finally, review the completed application for accuracy. You can then save your changes, download a copy, print it, or share the form as needed.

Complete your application for the Medicare Savings Program online today!