Get Declaration Of Prior Prescription Drug Coverage

Completing the Declaration Of Prior Prescription Drug Coverage accurately is essential for maintaining your Medicare prescription drug benefits. This guide will provide you with clear instructions on how to effectively fill out the form online, ensuring a smooth process.

Follow the steps to successfully complete the form online.

1. Click 'Get Form' button to obtain the form and open it in the editor.
2. Begin by entering the date at the top of the form. This helps establish when you are filling out the document.
3. Next, fill in your name in the 'Enrollee Name' section. Ensure that you use your full legal name as it appears on official documents.
4. Provide your current address in the designated address field. Accurate contact information is necessary for communication regarding the form.
5. Enter your phone number in the appropriate section. This will be used for any necessary follow-ups.
6. Include your Medicare Health Insurance Claim Number as indicated on your Medicare card. This verifies your eligibility.
7. Indicate the name of your Medicare Prescription Drug Plan in the given field. This links your previous coverage to your current plan.
8. Check all boxes that apply to you to indicate your prior prescription drug coverage. Make sure to provide the dates of coverage in the month/year format.
9. For each coverage type checked, fill in the corresponding 'From' and 'To' dates to specify the duration of your previous coverage.
10. If applicable, complete the section regarding your state residency and any relevant programs you participated in, such as Medicaid or TRICARE.
11. If you are completing the form on behalf of someone else, provide your details in the 'Representative Information' section, including relation to the enrollee.
12. Sign and date the form at the bottom, confirming that the information provided is accurate to the best of your knowledge.
13. Finally, save your changes, and download or print the completed form for your records. You can also share it as needed.

Take action now; complete the Declaration Of Prior Prescription Drug Coverage online today!