Forms

Request for Employment Information

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.

(EPIC) Elderly Pharmaceutical Insurance Coverage

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

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

Enrolling in Medicare Part B

Medicare Part B (medical insurance) is part of Original Medicare and covers medical services and supplies that are medically necessary to treat your health condition. This can include outpatient care, preventive services, ambulance services, and durable medical equipment. It also covers part-time or intermittent home health and rehabilitative services, such as physical therapy, if they are ordered by a doctor to treat your condition.

Some of the preventive services Medicare Part B covers include a one-time “Welcome to Medicare” preventive visit, flu and hepatitis B shots, cardiovascular screenings, cancer screenings, diabetes screenings, and more.