LEP Form

DECLARATION OF PRIOR PRESCRIPTION DRUG COVERAGE

1. Enter the date that is printed on the letter you received: *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar

Personal Information

2. Enrollee First Name *This question is required.

3. Middle initial

4. Last name *This question is required.

5. Street address *This question is required.

6. Apt #/PO box

7. City *This question is required.

8. State *This question is required.

9. Zip *This question is required.

10. Phone *This question is required.

11. Is the above phone number a mobile or land line? *This question is required.

12. Medicare Health Insurance Claim # *This question is required. This can be found on your red, white, and blue Medicare card or at the top of the form you received

13. Name of Medicare Prescription Drug Plan *This question is required.

14. Member ID *This question is required. This can be found at the bottom of the form you received after your name