› Medicare Prescription Payment Plan Participation Request Form

Medicare Prescription Payment Plan Participation Request Form

The Medicare Prescription Payment Plan is a voluntary payment option that works with your current drug coverage to help you manage your out-of-pocket Medicare Part D drug costs by spreading them across the calendar year (January-December). This payment option may help you manage your expenses, but it doesn’t save you money or lower your drug costs.

This payment option might not be the best choice for you if you get help paying for your prescription drug costs through programs like Extra Help from Medicare or a State Pharmaceutical Assistance Program (SPAP). Call your plan for more information.

Complete all fields unless marked optional

First Name*

Last Name*

Middle Initial

Medicare Number*

####-###-####

Birth Date*

MM/DD/YYYY

Phone*

Permanent Residence Street Address*

Permanent residence street address (don’t enter a P.O. Box unless you’re experiencing homelessness):

Street Address

City

State / Province / Region

ZIP / Postal Code

Is the Mailing Address the same as the Permanent Residence Address?*

Yes

Mailing Address*

If different from your permanent address (P.O. Box allowed)

Street Address

City

State / Province / Region

ZIP / Postal Code

Acknowledgement

I understand this form is a request to participate in the Medicare Prescription Payment Plan. Leon Health, Inc. will contact me if they need more information.
I understand that signing this form means that I’ve read and understand the form.
Leon Health, Inc. will send me a notice to let me know when my participation in the Medicare Prescription Payment Plan is active. Until then, I understand that I’m not a participant in the Medicare Prescription Payment Plan.

Are You a Representative?

If you’re completing this form for someone else, complete the section below. By checking this checkbox, you certify 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.

Date

Name

Phone

Address

(Street, City, State, ZIP code)

Relationship to Participant

Name*

Phone*

Address*

(Street, City, State, ZIP code)

Relationship to Participant*

You can also call us at 1-844-969-5366 to submit your request via telephone.

If you have questions or need help completing this form, call us at 1-844-969-5366, from Monday to Sunday 8 a.m. – 8 p.m. from October to March, and Monday to Friday 8 a.m. – 8 p.m. from April to September. TTY users can call 711.

Name

This field is for validation purposes and should be left unchanged.

Call Us Today

Toll-Free Number:
1-844-969-5366 (TTY: 711)

Local Number:
(305) 541-5366 (TTY: 711)

Hours of Operation
Monday – Sunday
8 a.m. – 8 p.m.
October to March

Monday – Friday
8 a.m. – 8 p.m.
April to September

Have Questions?

Leon Health, Inc.
8600 NW 41st St, Suite 210
Doral, FL 33166

Contact Us:
Fill this form and one of our licensed agents will call you back.

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