Enrollment Request Form - 2017 Page 7

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For more information about this Extra Help, contact your local Social Security office, or call Social
Security at 1-800-772-1213. TTY users should call 1-800-325-0778. You can also apply for Extra Help
online at
A few questions to help us manage your plan.
1. Would you prefer plan information in another language or format?
¨ Yes ¨ No
Please check what you’d like: ¨ Spanish
¨ Other_______________
If you don’t see the language or format you want, please call us at 1-888-867-5564, TTY 711 during
8 a.m. - 8 p.m. local time, 7 days a week. Or visit for online help.
2. Do you live in a nursing home or a long-term care facility?
¨ Yes ¨ No
If yes, please give us information on the long-term care facility:
Name
City
State
ZIP Code
Address
/
/
Phone Number (
)
--
M M
D D
Y Y Y
Date You Moved There
¨ Yes ¨ No
3. Do you have other insurance that will cover your prescription drugs?
Examples: Other private insurance, TRICARE, Federal employee coverage, VA benefits, or state
programs.
If yes, what is it?
Name of Other Insurance
Member ID Number
Group ID Number
Date Plan Started
/
/
M M
D D
Y Y Y Y
Please read and sign
By completing this form, I agree to the following:
This is a Medicare Prescription Drug plan. It has a contract with the federal government. This
·
Prescription Drug coverage is in addition to Original Medicare. This is not a Medicare
Supplement plan.
I need to keep my Medicare Parts A or B. I must keep paying my Part B premium if I have one,
·
unless Medicaid or someone else pays for it.
I can only be in one Medicare prescription drug plan at time-if I am currently in a Medicare
·
Prescription Drug Plan, my enrollment in this plan will end that enrollment.
If I have prescription drug coverage now or if I get it from somewhere else later, I will tell the
·
plan.
Enrollee Name
PDEX17PD3877053_000
Y0066_160609_110859 Approved

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