| 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 |
