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:

Online:

Complete the required fields and click submit.

By FAX/Mail:

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.

Patient Attestation

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.

Patient Information

First Name:

Last Name:

DOB:

Street Address:

City:

State:

Zip:

Signature

Signature Preview

Date

12/04/2020

Date:

Download Blank Application

Medicare Annual Re-Enrollment Patient Attestation Form

How to complete this form:

Online:

By FAX/Mail:

Patient Attestation

Patient Information

Questions? Call 1-800-292-6363 Monday–Friday, 9:00 AM to 6:00 PM ET or visit www.azandmeapp.com.