Complete the required fields and click submit.
Medicare Annual Re-Enrollment Patient Attestation Form
Important Note: Your prompt review and return of this form will allow us to continue processing your enrollment in the AZ&Me Program for the 2021 calendar year.
How to complete this form:
- Review the information on this page carefully and save a copy for your records.
- Complete this form and fax or mail it to:Fax: 800-961-8323Mail: PO Box 222178, Charlotte, NC 28222
Once we receive your attestation form, we will continue processing your enrollment for the 2021 calendar year. Upon completion, you will receive a determination letter in the mail.
NOTE: Attestation re-enrollment is for re-enrolling Medicare patients ONLY. Uninsured and first-time enrolling Medicare patients must submit a full enrollment form, available at www.azandmeapp.com.
By signing below, I attest that the following is accurate and true and understand that any misrepresentation of my information is grounds for removal from the AZ&Me Program:
- I am still on therapy supported by the AZ&Me Program.
- I am still in need of financial support.
- I have had no changes in insurance status, income, or US residency status since my approval into the AZ&Me Program
that would make me ineligible for the Program.