Application For Medicare Savings Program (Qmb, Slmb, Qi)

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Thank you for your interest in the
Medicare Savings Program.
State Form 49228 (R5 / 8-11)
• To apply, please fill out both sides of the attached application. If there are parts that you
do not understand, it is okay to leave them blank. However, you must complete section
1 and sign sections 13 and 14 on the back.
• All members of your household who have Medicare Part A can apply for assistance on
this one application. This is true even if you do not currently have Medicare Part B. In
section 1, be sure to place a
in the last column for the persons who are applying.
• You will need to provide copies of certain documents to help us determine your eligibility
such as:
Your Medicare card;
Your most recent statements for all bank accounts, annuities, stocks, bonds, etc.;
Property deeds (for property that is not the home you are living in);
Life insurance policies;
Funeral trust documents;
Proof of income;
Immigration documents for lawful immigrants;
Identification card for other health insurance such as Medicare supplement.
If you do not have all of the documents that we need, you can sign a consent form and we will
get the information.
• If you are eligible for the Medicare Savings Program, it will take at least 3-4 months for the
Social Security Administration to stop withholding the Part B premium from your check.
However, you will receive a refund check for the full amount of premiums that we owe you.
If you received this application in the mail, you may return it to us after you fill it out. Send it to:
RIGHTS AND RESPONSIBILITIES UNDER MEDICAID AND THE MEDICARE SAVINGS PROGRAM
Please read this information carefully.
1. The information you provide is confidential. (42 CFR 431.300, 470 IAC 1-2-7, 470 IAC 1-3-1,
470 IAC 6-1-1, 405 IAC 1-1-12.)
2. If you cannot get the papers needed to determine your eligibility, you must sign a consent for
release of information and we will get them for you.
3. Eligibility is considered without regard to race, color, creed, sex, age, disability, national
origin, or political belief.
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