Application for Medicare Savings Programs
Alabama Medicaid Agency
NOTE: This is NOT an application for full Medicaid. These programs cover Medicare premiums and deductibles.
Medicaid’s drug coverage is limited to the drugs covered under Medicare Part D only. Medicaid will not pay for any
excluded drugs under Medicare Part D.
Instructions: Read this application carefully and follow all instructions given throughout the form. Answer each
question completely and accurately.
1. Send a copy of your Medicare card to verify your Part A coverage.
2. Send a copy of your Social Security card.
3. Send verification of the gross (before taxes) amount of your monthly
income other than Social Security.
4. Sign the application.
5. Mail the application to the District Office serving your county.
(See last page of this application for a list of District Offices,
addresses and phone numbers.)
6. Please print using dark ink.
P.O. Box City State Zip Code
County where you live __________________________ Telephone Number (_______) __________________
Social Security Number: _________________________ Date of Birth _______________________________
Race: ___ White
___ American Indian
Sex: ___ Female ___ Male
Do you have Medicare Part A (Hospital) Coverage? o Yes o No
Name on Medicare card: _______________________________ Medicare No. _______________________
Sponsor: (If the applicant is unable to complete the applicati