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Get SSA-1020B-OCR-SM-INST 2014-2021

The SHIP offers help with your Medicare questions. Please mail your application today. Carolyn W. Colvin Acting Commissioner Form SSA-1020B-OCR-SM-INST 01-2013 Recycle prior editions General Instructions for Completing the Application for Extra Help with Medicare If You Are Assisting Someone Else With This Application Answer the questions as if that person were completing the application. You must know that person s Do you have Medicare and Supplemental Security Income SSI or Medicare and Medicaid If the answer is YES do not complete this application because you automatically will get the Extra Help. Does your State Medicaid program pay your Medicare premiums because you belong to a Extra Help automatically and may not need to complete this application. How To Complete This Application Use BLACK INK only Keep your numbers letters and inside the boxes use only CAPITAL letters Do not add any handwritten comments on the application Do not use dollar signs when entering money amounts and Cents can be rounded to the nearest whole dollar. Social Security Administration Important Information THIS COVER LETTER IS FOR INFORMATION ONLY. DO NOT COMPLETE THE FOLLOWING PAGES* THIS IS NOT AN APPLICATION* You may be eligible to get Extra Help paying for your prescription drugs. The Medicare prescription drug program gives you a choice of prescription plans that offer various types of coverage. In addition you may be able to get Extra Help to pay for the monthly premiums annual deductibles and co-payments related to the Medicare prescription drug program* But before we can help you you must fill out this application put it in the enclosed envelope and mail it today. Or you may complete an online application at www. socialsecurity. gov* We will review your application and send you a letter to let you know if you qualify for Extra Help* To use the Extra Help you must enroll in a Medicare prescription drug plan* If you need help completing the application call Social Security at 1-800-772-1213 TTY 1-800-325-0778. You can find more information at www. socialsecurity. gov* You also may be able to get help from your State with other Medicare costs under the Medicare Savings Programs. By completing this form you will start your application process for a Medicare Savings Program* We will send information to your State who will contact you to help you apply for a Medicare Savings Program unless you tell us not to by answering question 15 on this form* If you need information about Medicare Savings Programs Medicare prescription drug plans or how to enroll in a plan call 1-800-MEDICARE 1-800-633-4227 TTY 1-877-486-2048 or visit www. medicare. gov* You also can request information about how to contact your State Health Insurance Counseling and Assistance Program SHIP. EXAMPLE Place an X in the box. DO NOT fill in or use check marks in boxes. X CORRECT Use capital letters when entering answers A B C D Completing Your Application You may complete the online application at www..

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