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MMA 2003

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

 

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