Click the links below to open and download forms Request for Employment Information WHAT IS THE PURPOSE OF THIS FORM? In order 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 Patients Request for Medical Payment Form Use this form to request payment for medical procedures back from Medicare please review carefully and provide all the information that they will need to process your claim.

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