Doh 4392-2025

See details

4 out of 5

20 votes

The document informs EPIC members about their potential eligibility for 'Extra Help,' a federal benefit that assists with Medicare Part D costs and prescription drug expenses. It requires members to complete and return a Request for Additional Information form within 30 days to maintain their EPIC coverage. The letter emphasizes the importance of providing accurate income and asset information, offers assistance options, and outlines the benefits of being approved for Extra Help.

Here's how it works

01. Edit your 3742 4392 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 doh 4392 with our platform

Ease of Setup

DocHub User Ratings on G2

Ease of Use

DocHub User Ratings on G2

Click ‘Get Form’ to open the doh 4392 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, and Social Security Number. If married, also provide your spouse's details.
In the income section, enter your current monthly income for each category listed (e.g., Social Security, Veterans Benefits). If you have no income for a category, enter $0.
For assets, report balances for bank accounts and investments. Remember not to include your home or personal possessions.
Complete questions regarding funeral expenses and real estate ownership as applicable. If single, answer based on your own assets; if married, use combined figures.
Finally, review all entries for accuracy before signing and dating the form at the bottom. Ensure any assistance received is noted if applicable.

Start using our platform today to complete your doh 4392 form easily and for free!