Get 2011 Individual Application Final 110225.doc

This guide provides clear instructions for users on how to effectively fill out the 2011 Individual Application FINAL 110225.doc online. Whether you are applying for assistance or helping someone else, this step-by-step approach will ensure you complete the application correctly.

Follow the steps to complete the application form accurately.

1. Click the ‘Get Form’ button to access the application form and open it in your chosen editing platform.
2. Start by filling out the 'Patient Information' section, which includes providing your first name, middle initial, last name, date of birth, street address, city, state, zip code, social security number, and phone number.
3. If your mailing address is different from your street address, please fill in that information as well.
4. Indicate your total annual household income, ensuring you include all sources of income such as wages, social security, pensions, and any other financial support.
5. Specify your household size by entering the number of persons living in your home and answer the eligibility questions regarding Medicare Part D and other prescription drug coverage.
6. Review the attestation statement, indicating your understanding of the program's requirements and providing your signature and date to confirm all information is accurate.
7. Move on to the 'Healthcare Provider Information' section, where the prescribing practitioner must provide their name, professional designation, state license number, and facility name.
8. Input the shipping address for medications, noting that they cannot be shipped to a patient's home or a P.O. Box.
9. The healthcare provider should list the prescribed medication's name, strength, and quantity per day. If there are any changes to the dosage schedule, this must be noted.
10. The healthcare provider must also sign and date the form to authorize that all information provided is complete and accurate.
11. After completing the form, ensure all sections are filled accurately. You can save your changes, download the completed application, print a copy, or share it with required parties.

Start filling out your application online today to ensure your best chance at assistance.