Medicare Premium Payment Program Application - RI Department of - dhs ri 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the 'Applicant Information' section. Enter your last name, first name, middle initial, primary language, telephone number, Social Security number, and date of birth.
3. Provide your residence and mailing addresses. If they are different, ensure you complete both fields accurately.
4. Indicate your entitlement to Medicare by checking 'Yes' or 'No' for Part A and Part B. Include your Medicare Claim Number as shown on your card.
5. If applicable, complete the 'Spouse Information' section with similar details about your spouse.
6. In the 'Income' section, list all sources of income for both you and your spouse. Be sure to include amounts for each type of income.
7. Detail any resources owned by you and your spouse in the 'Resources' section. This includes bank accounts, stocks, bonds, and other assets.
8. Review the declarations at the end of the form carefully before signing. Ensure all information is accurate and complete.

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