Get Online Application For Epic For Elderly Form

Filling out the Online Application For Epic For Elderly Form is a crucial step for seniors seeking financial assistance with their prescription medications. This guide will provide you with detailed instructions to help you navigate the application process with ease.

Follow the steps to complete the application efficiently.

1. Press the ‘Get Form’ button to obtain the form and open it in your browser.
2. Clearly print your personal information in the designated fields, including your last name, first name, middle initial, social security number, and sex. Ensure that you also include the date of birth in the required format (day, month, year).
3. Provide your current address where you reside, making sure to omit P.O. Box addresses. Include the city, state, and ZIP code.
4. If your mailing address differs from your residential address, fill in that information as well. Provide your telephone number, including the area code.
5. Indicate your marital status. If you are married, provide your spouse’s information, including their name, date of birth, and social security number.
6. Input your Medicare claim number and your spouse’s Medicare claim number, if applicable.
7. Report the total annual income for the previous calendar year. If you are married and living together, combine your incomes and ensure both parties sign the application.
8. Carefully read the certification statement, acknowledging your understanding of the requirements outlined. Sign and date the application accordingly, ensuring both you and your spouse sign if living together.
9. If you desire to authorize EPIC to share your information with specific persons involved in your healthcare, print their names in the designated area.
10. Once the form is completed, mail it to the address provided or consider faxing it to the number listed for submissions.

Start completing the Online Application For Epic For Elderly Form online today!