Request for Employment Information

To apply for Medicare in a Special Enrollment
Period, you must have or had group health plan coverage
within the last 8 months through your or your spouse’s
current employment. People with disabilities must have large
group health plan coverage based on your, your spouse’s or
a family member’s current employment.
This form is used for proof of group health care coverage
based on current employment. This information is needed to
process your Medicare enrollment application.
The employer that provides the group health plan coverage
completes the information about your health care coverage
and dates of employment.


Enrolling in Part B


Part B covers 2 types of services

You pay nothing for most preventive services if you get the services from a health care provider who accepts assignment.




(Epic) Elderly Pharmaceutical Insurance Coverage Program


The Elderly Pharmaceutical Insurance Coverage (EPIC) program is a New York State program administered by the Department of Health. It provides seniors with co-payment assistance for Medicare Part D covered prescription drugs after any Part D deductible is met. EPIC also covers many Medicare Part D excluded drugs.


For more information call the toll-free EPIC Helpline at 1-800-332-3742


Medicare Income Related Monthly Adjustment Amount for Life-Changing Event

If you had a major life-changing event and your income has gone down, you may use this form to request a reduction in your income-related monthly adjustment amount. See page 5 for detailed information and line-by-line instructions. If you prefer to schedule an interview with your local Social Security office, call 1-800-772-1213

Click here to learn about Medicare Part A