Get Lep Form

The Part D Late Enrollment Penalty Reconsideration Request Form, commonly referred to as the Lep Form, is designed to facilitate an appeal regarding late enrollment penalties associated with Medicare Part D. Following this guide will help you navigate the process of filling out this form online with ease.

Follow the steps to successfully complete the Lep Form online.

1. Click ‘Get Form’ button to access the Lep Form and open it in your document editor.
2. Enter the date at the top of the form. This should reflect the current date of your application.
3. Fill in the Medicare Appeal number. This section is specifically for use by MAXIMUS Federal Services and can be left blank if not applicable.
4. Provide the enrollee's name, address, city, state, zip code, and phone number. Ensure that all information is accurate and up-to-date.
5. Input the Medicare Health Insurance Claim number from your Medicare card and the enrollee's date of birth in MM/DD/YYYY format.
6. Indicate the name of your current Part D drug plan in the designated section.
7. A signature by the enrollee is required for this form to be valid. Ensure the enrollee signs and dates the form appropriately.
8. Check all applicable boxes that explain the reason for your reconsideration request. Provide any necessary evidence or documentation to support your claims.
9. If additional information is needed, feel free to attach separate sheets explaining your circumstances, including any correspondence that may validate your prior coverage.
10. After completing the form, review all entries for accuracy. Save your changes, download the form, and print it if you need a physical copy.
11. Submit the completed form as directed, either by mailing it to MAXIMUS Federal Services or faxing it to the provided numbers.

Take the next steps towards your Medicare appeal and complete the Lep Form online today.