Application Forms

Application Forms

BenefitsCheckUp
Sponsored by the National Council on Aging, BenefitsCheckUp (link to www.benefitscheckup.org) is a web tool that allows your patients to apply online for the Medicare Part D Extra Help/Low-Income Subsidy. They can also learn about other benefits for which they may be eligible.

AZ&Me™ Prescription Savings Programs
If your patients take any AstraZeneca medicines and have difficulty affording them, they may qualify for one of AstraZeneca's patient assistance programs. A family of four without prescription coverage making up to $60,000 per year may qualify for patient assistance. A patient enrolled in Medicare Part D may also qualify for assistance. You can download applications for the program through the links below.