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For CDPH Staff Use Only Date ReceivedStaff Initial

For CDPH Staff Use Only Date ReceivedStaff Initial 2025

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The document outlines the application process for the 2012 Medicare Part D Premium Payment Program administered by the California Department of Public Health (CDPH). It includes sections for applicant information, Medicare Part D plan details, and consent for the release of personal and medical information. The program aims to assist eligible California residents with their insurance premiums under the Ryan White Treatment Extension Act of 2009. Key eligibility requirements are specified, along with instructions for submitting applications and necessary forms.

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