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REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION This form may be sent to us by mail or fax: Address: Appeals Department MC 109 PO Box 52000 Phoenix, AZ 850722000 Fax Number: 18556337673

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6. If there are any additional documents or supporting materials required, make sure to attach them to the form according to the instructions provided.
7. Finally, sign and date the form, if applicable. Some forms may require your signature as a confirmation of the information provided.
8. Once you have completed the form, submit it as instructed. Retain a copy of the form and any attachments for your records.

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What is this form may be?

This form is a tax form used for reporting income to the IRS.

Who is required to file this form may be?

Individuals or businesses who have received income during the tax year may be required to file this form.

How to fill out this form may be?

This form can be filled out manually or electronically, depending on the preference of the filer.

What is the purpose of this form may be?

The purpose of this form is to report income and calculate the amount of tax owed to the IRS.

What information must be reported on this form may be?

Information such as total income, deductions, and tax credits must be reported on this form.