Medicare Prescription Payment Plan

Medicare Prescription Payment Plan Form
Member Name

First NameMiddle InitialLast Name
Medicare Number
Troy Medicare Member Number
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Please Indicate the Phone Type (Home, Cellphone*, etc.)
Permanent Residence Address (Do not enter a P.O. Box unless you're experiencing homelessness)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is your mailing address the same as your permanent residence address?
Mailing Address, if different from your permanent address (P.O. Box allowed)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Read and sign below. Must check all boxes
Date of Completion

MonthDayYear
Date
Time of Completion

Hour Minutes

AM/PM Option
Signature
Are you completing this form for someone other than yourself?
If you’re completing this form for someone else, complete the section below. Your signature certifies that you’re authorized under State law to fill out this participation form and have documentation of this authority available if Medicare asks for it.
Representative Name

First NameMiddle InitialLast Name
Representative Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Participant
Date of Completion

MonthDayYear
Date
Time of Completion

Hour Minutes

AM/PM Option
Representative Signature
I understand all parts of this form along with the terms and conditions, and agree to opt-in this program.
*By providing your phone number, you consent to receive text messages from us regarding important updates, reminders, and information related to your health insurance coverage. Message frequency may vary. Standard message and data rates may apply. You can opt-out at any time by replying STOP to any message.
Should be Empty:

Medicare Prescription Payment Plan Form