Community Health Group | Medicare Prescription Payment Plan Participation Request Form

Medicare Prescription Payment Plan Participation Request Form

Complete all fields unless marked optional
* Required Field

First Name

Last Name

Middle Initial (optional)

Medicare Number

Birth Date

Phone Number

10 digits phone number

Permanent residence street address (don't enter a P.O. Box unless you're experiencing homelessness)

City

County (optional)

State

2 letters state

Zip Code

5 digits zip code

Mailing address, if different from your permanent address (P.O. Box allowed)

City

State

2 letters state

Zip Code

5 digits zip code

Do you get help paying your prescription drug costs from a program like Medicare’s Extra Help, a State Pharmaceutical Assistance Program (SPAP), Indian Health Services, or other health insurance?

Yes
No
Not sure

Acknowledgement

I understand this form is a request to participate in the Medicare Prescription Payment Plan. Community Advantage Plus will contact me if they need more information.

I understand that signing this form means that I've read and understood the form.

Community Advantage Plus will send me a notice to let me know when my participation in the Medicare Prescription Payment Plan is active. Until then, I understand that I'm not a participant in the Medicare Prescription Payment Plan.

Please Enter Electronic Signature

Date

If you're completing this form for someone else, complete the section below. Your signature certifies that you're authorized under State law to fill out the participation form and have documentation of this authority available if Medicare asks for it.

I am completing this form for someone else

Name

Address (Street, City, State, Zip Code)

Phone Number

10 digits phone number

Relationship to Participant