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Enrollment Forms for the Medicare Approved Drug Discount Card

CMS Form Number Description Title
CMS 20016A English PDF (233 KB)

Spanish PDF (139 KB)
STANDARD ENROLLMENT FORM FOR THE MEDICARE-APPROVED DRUG DISCOUNT CARD
CMS 20016B English PDF (249 KB)

Spanish PDF (141 KB)
STANDARD ENROLLMENT FORM FOR THE MEDICARE-APPROVED DRUG DISCOUNT CARD AND ADDITIONAL ASSISTANCE IN PAYING FOR YOUR PRESCRIPTION DRUGS
CMS 20016E English PDF (387 KB)

Spanish PDF (64 KB)
MEDICARE-APPROVED PRESCRIPTION DRUG DISCOUNT CARD INSTRUCTION SHEET FOR COMPLETING FORMS CMS 20016 A - D

Page Last Updated: April 10, 2007

 

 
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