Prescription Drug Assistance
Social Security Number: 123-00-6789
JOHN Q. PUBLIC
123 MAIN ST
SPRINGFIELD OH 45501
This is a very important letter and could affect whether you get extra help to pay
for your prescription drugs. Please read carefully. If there is anything you do not
understand, please get in touch with us right away.
What You Need To Do
Please furnish the information requested below and return this letter. (Only the checked box applies to you.)
[ ] Answer the following question (s).
(Drop Down Box)
Have you or your spouse (if married and living together) set aside any money for burial
Your spouse (if living together): _____Yes______No
[ ] Clarify the responses to the following question(s) ________________________________
If We Do Not Hear From You
We may deny your Application for Help with Medicare Prescription Drug Plan Costs if
you do not respond to this request or contact us by November 20, 2005.
If You Have Any Questions
If you have any questions or need help, please call us at the telephone number shown
at the top of this letter and ask for Mr.