Get Ny Maximus Federal Services Part D Late Enrollment Penalty (lep) Reconsideration Request Form 2020-2025

This guide provides clear, step-by-step instructions on how to complete the NY MAXIMUS Federal Services Part D Late Enrollment Penalty Reconsideration Request Form online. By following these steps, users with varying levels of experience can successfully submit their appeals.

Follow the steps to complete the form accurately and effectively.

1. Press the ‘Get Form’ button to obtain the Part D Late Enrollment Penalty Reconsideration Request Form. This will allow you to access the document in an editable format.
2. Begin filling out the form by entering the date in the designated field, followed by your Medicare Appeal number, which is for MAXIMUS Federal Services use only.
3. Next, provide your personal information, including your enrollee name, address, city, state, zip code, and phone number. This information is crucial for MAXIMUS to identify and respond to your request.
4. Enter your Medicare number as it appears on your Medicare card, along with your date of birth in the format MM/DD/YYYY.
5. Indicate the name of your current Part D drug plan. This helps to establish the context of your appeal.
6. Ensure you provide a signature in the designated area, as it is required for processing your appeal. The enrollee must sign the form.
7. Select all boxes that apply to your situation regarding the late enrollment penalty and provide any required evidence as listed.
8. If necessary, attach additional documents that you believe support your case, such as proof of creditable coverage or reasons for delay if it has been more than 60 days since the penalty notice.
9. Review all entered information for accuracy and completeness before finalizing the form.
10. Once satisfied with your entries, save the completed form to your device. You can then print it or share it as needed.

Submit your NY MAXIMUS Part D Late Enrollment Penalty Reconsideration Request Form online to ensure prompt processing of your appeal.