Forms & Resources

The following resources can be accessed or printed from this page:

Medicare Savings Programs – Help Paying for Medicare Premiums

Mail-In Application for Qualified Medicare Beneficiaries (QMB) and Specified Low-Income Medicare Beneficiaries (SLMB) Programs

Application Link: QMB/SLMB Application

Mail the completed application to:

Montgomery County DHHS
c/o Rodney Glasgow
1301 Piccard Drive – 2nd Floor
Rockville, MD 20850
(240) 777-4451


Medicare Part D Drug Assistance Programs – Help Paying for Prescription Drug Costs

On-Line Application for Low Income Subsidy/Extra Help – (Federal Government Program)

Application Link: LIS Application page (Scroll to the bottom of the page for the Apply Now button)

Forms are available by mail from the SHIP office at 301-590-2819 or from the Social Security Office at 1-800-772-1213.

Mail the completed application to:

Social Security Administration
Wilkes-Barre Data Operations Center
PO Box 1020
Wilkes-Barre, PA 18767-9910

Mail-In Application for the Maryland Senior Prescription Drug Assistance Program (State of Maryland Program)

Application Link: Maryland SPDAP Application

Mail the completed application to:

Maryland Senior Prescription Drug Assistance Program – SPDAP
c/o Pool Administrators
628 Hebron Avenue, Suite 100
Glastonbury, CT 06333
1(800) 551-5996

SHIP can recommend a Medicare Part D Prescription Drug Plan for MONTGOMERY COUNTY MD RESIDENTS ONLY. Download and complete the Medicare Part D Prescription Drug Worksheet

Worksheet Link: 2017 Part D Prescription Drug Worksheet

Mail the completed worksheet to:

SHIP
12320 Parklawn Drive
Rockville, MD 20852
(301) 255-4250


Medigap/Medicare Supplement Policies

Standardized policies issued in the state of Maryland that fill coverage gaps in the original Medicare Program (Part A & B)

Medicare Supplement Chart – Monthly Premiums for Medicare Supplement Policies: Medicare Supplement Chart – January 2017


Additional Medicare Information

SHIP Fact Sheet:  Understanding Medicare: Understanding Medicare 

Official U.S. Government Medicare Handbook:  Medicare & You – 2017