Patient Assistance Program for Medicare Beneficiaries Application 2025

1. Click ‘Get Form’ to open the Patient Assistance Program for Medicare Beneficiaries Application in our editor.
2. Begin with Section 1, where you will need to enter all physician and prescription information. Ensure that the physician's signature is included.
3. Move to Section 2 and fill in all required patient information, including name, address, date of birth, and social security number.
4. In Section 3, list all sources of income and attach proof of income documents as specified. This includes your most recent federal tax return.
5. Complete Section 4 regarding Social Security Low Income Subsidy. If applicable, attach any denial letters from the previous year.
6. Fill out Section 5 by providing details on prescription drug coverage and total out-of-pocket expenses for prescriptions since January 1.
7. Finally, sign and date Section 6 to confirm the accuracy of your application before submitting it through our platform.

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