Click the links below to open and download forms
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.
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.
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