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Click ‘Get Form’ to open the Part D Late Enrollment Penalty (LEP) Reconsideration Request Form in the editor.
Begin by entering the date at the top of the form. Next, fill in your Medicare Appeal number if applicable.
Provide your personal information including your name, address, city, state, zip code, phone number, and Medicare Health Insurance Claim number from your Medicare card.
Enter your date of birth in MM/DD/YYYY format and specify the name of your current Part D Drug Plan.
Check all applicable boxes that explain why you believe the late enrollment penalty is incorrect. Be sure to attach any required evidence for each reason selected.
Sign and date the form at the bottom. Remember that a signature is mandatory for processing your appeal.
Finally, send this completed form along with any additional documents to MAXIMUS Federal Services using the provided address or fax number.

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