Follow the steps to complete your application online.

1. Click ‘Get Form’ button to obtain the form and open it in the editing interface.
2. Fill in your personal information, including your name, address, and contact details. Ensure that the information is accurate to avoid delays in processing.
3. Provide information about your resources and income. This includes listing your bank accounts, real estate (excluding your primary residence), stocks, and any other assets.
4. Enter details about your income. Include information from Social Security benefits, pensions, and any other sources of income you or your spouse receive.
5. Review the information you have entered to ensure accuracy and completeness. Make any necessary corrections.
6. Submit your application once all information has been thoroughly checked. You may have options to save changes, download, print, or share the form if required.

Start your application for Extra Help with your Medicare prescription drug plan online today!