Home
Forms Library
Request for Additional Information Instructions Call the EPIC ...

Request for Additional Information Instructions Call the EPIC ... 2026

Request for Additional Information Instructions Call the EPIC ... Preview on Page 1

See details

4.9 out of 5

28 votes

The document is a Request for Additional Information form for the EPIC program, requiring individuals to provide details about their marital status, income, and assets to maintain coverage. It includes specific instructions for both single and married applicants on how to report financial information, as well as questions regarding dependents and expected earnings.

Here's how it works

01. Edit your form online

Type text, add images, blackout confidential details, add comments, highlights and more.

02. Sign it in a few clicks

Draw your signature, type it, upload its image, or use your mobile device as a signature pad.

03. Share your form with others

Send it via email, link, or fax. You can also download it, export it or print it out.

How to use or fill out Request for Additional Information Instructions Call the EPIC ... with our platform

Ease of Setup

DocHub User Ratings on G2

Ease of Use

DocHub User Ratings on G2

Click ‘Get Form’ to open it in the editor.
Begin by selecting your marital status at the top of the form. Choose either 'Single' or 'Married' based on your situation.
Fill in your personal information, including your name, EPIC ID number, and contact details. Ensure all entries are clear and accurate.
For income details, enter your current monthly income for each category listed (e.g., Social Security, Veterans Benefits). If you have no income for a line, enter $0.
In the Assets section, report balances for bank accounts and investments. Remember not to include your home or personal possessions.
If applicable, answer questions regarding relatives living with you and their financial dependency on you.
Finally, review all entries for accuracy before signing and dating the form at the bottom. If someone assisted you, provide their contact information as well.

Start using our platform today to easily complete and submit your Request for Additional Information form!

See more Request for Additional Information Instructions Call the EPIC ... versions

We've got more versions of the Request for Additional Information Instructions Call the EPIC ... form. Select the right Request for Additional Information Instructions Call the EPIC ... version from the list and start editing it straight away!

Versions	Form popularity	Fillable & printable
2017	4.9 Satisfied (28 Votes)
2010	4 Satisfied (20 Votes)

be ready to get more

Complete this form in 5 minutes or less

Get form

Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

How can I eSign my Request for Additional Information Instructions Call the EPIC ... in Word?

Microsoft Word doesn’t have signing tools to create legitimate eSignatures and enforceable paperwork. Fortunately, DocHub is an online eSignature-compliant editor that supports various document formats, including .doc files. Log in to your account and add the Word version of your Request for Additional Information Instructions Call the EPIC ... from your device and cloud, or URL - our editor will automatically turn it into an editable PDF. Make all essential adjustments in your form and click Sign to create your own legally-binding electronic signature. You will find four signing methods from which to choose.

How do you edit Request for Additional Information Instructions Call the EPIC ... online?

With DocHub, you have several convenient methods to edit your Request for Additional Information Instructions Call the EPIC ... online. You can drag and drop the form and edit it directly at the DocHub website or use our browser extension to fill out your form right away. Additionally, you can edit your PDF on your phone, as DocHub works with all the available mobile platforms.

Who is eligible for epic in NY?

To qualify for the EPIC Deductible plan, your income must range from $20,001-$75,000/year if single and $26,001-$100,000/year if married. If your income is between $20,001-$23,000 and you are single, or $26,001-$29,000 and you are married: You will not have to pay an annual fee to have EPIC.

How do I contact NYS Epic?

EPIC operates a toll-free Helpline which is available from 8:00AM to 5:00PM, Monday through Friday. Call 1-800-332-3742 (TTY 1-800-290-9138) for more information or to request an application. Or email us at: nysdohepic@primetherapeutics.com.

How to apply for Epic in New York?

The Elderly Pharmaceutical Insurance Coverage (EPIC) program is a New York State Program administered by the Department of Health. It provides seniors with co-payment assistance for Medicare Part D covered prescription drugs after any Part D deductible is met. EPIC also covers many Medicare Part D excluded drugs.

What are the qualifications for Epic?

You must meet the eligibility requirements for the EPIC program: be 65 years old or older, be a New York State Resident, and. have income up to $75,000 for a single person or up to $100,000 for a married couple living together.

Who is eligible for NY State Epic?

Currently, the types of credentials a physician can upload to EPIC are: Final Medical Diploma. Alternate Graduation Document. Final Medical School Transcript. Student Medical School Transcript. Pregraduate Internship Certificate. Postgraduate Training Credential. Specialist Qualification. Certificate of Good Standing.

Request for Additional Information Instructions Call the EPIC ... 2026

Here's how it works

How to use or fill out Request for Additional Information Instructions Call the EPIC ... with our platform