Get No Prescription Coverage For Medicare Part D Coverage ...

This guide provides supportive and clear instructions for users looking to fill out the No Prescription Coverage for Medicare Part D Coverage application online. Follow these steps to ensure the process is smooth and your application is complete.

Follow the steps to complete your application

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Carefully read the program eligibility criteria listed on the form. Ensure you meet the requirements such as having an FDA-approved diagnosis and being a permanent resident of the United States.
3. Complete Section A of the application with your personal information, including your name, date of birth, address, and contact details.
4. Provide your marital status and confirm whether you reside permanently in the U.S. Additionally, indicate your consent for the program to leave voice messages.
5. In the insurance information section, check any applicable insurance coverage and provide details such as policyholder name and insurance numbers.
6. Fill out your total annual gross household income and household size. Include proof of income if required.
7. In Section B, your healthcare provider must fill out the patient diagnosis and prescriber information accurately, stating the primary diagnosis and medications.
8. Sign the application in the required sections as both the patient and the healthcare provider to authorize the submission.
9. Ensure all sections are completed. Then, fax the completed application with the required documents to 1-844-269-3053. If you do not have a fax, mail the documents to the specified address.
10. Keep a copy of the completed form for your records and confirm that your application has been received.

Start the application process online now to access the assistance you need.