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REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION This form may be sent to us by mail or fax: Address: Pharmacy Services PO Box 1520 JAF Station New York, NY 10116-1520 Fax Number: 1-877-300-9695

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8. Sign and date the form, if required. Follow any additional instructions related to submission, such as attaching supporting documents, making a copy for your records, or sending the form through a specific channel.
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Who needs this form:

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What is this form may be?

This form may be a tax form used for reporting income.

Who is required to file this form may be?

Individuals or businesses who have earned income may be required to file this form.

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This form may be filled out by providing accurate information about income and expenses.

What is the purpose of this form may be?

The purpose of this form may be to report income to the government for tax purposes.

What information must be reported on this form may be?

Information such as income, expenses, and deductions may be reported on this form.

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