Declaration of prior prescription drug coverage 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the date at the top of the form. Next, fill in your name, address, and phone number in the designated fields.
3. Provide your Medicare Health Insurance Claim Number from your Medicare card. Then, specify the name of your Medicare Prescription Drug Plan.
4. Check all applicable boxes regarding your prior prescription drug coverage. For each option selected, enter the corresponding dates of coverage in month/year format.
5. If you have extra help from Medicare or lived in an area affected by Hurricane Katrina, ensure to provide additional details as required.
6. Complete the declaration section by affirming that the information provided is true and correct. Sign and date the form at the bottom.
7. If applicable, fill out representative information if someone else is completing this form on your behalf.

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