contact your case manager with any questions or concerns. Please initial and sign the document. ... ADAP Operations Mana
AFFIDAVIT OF UNDERSTANDING FOR INDIVIDUALS ENROLLED IN A MEDICARE HEALTH PLAN OR A MEDICARE PRESCRIPTION DRUG PLAN BEFORE SIGNING, READ THIS DOCUMENT CAREFULLY AND BE SURE YOU UNDERSTAND. If you have any questions, please call ADAP at 602-364-3610 or 800-334-1540. You may also contact your case manager with any questions or concerns. Please initial and sign the document. As an individual enrolled in a Medicare health plan or a Medicare prescription drug plan, I understand I am required to give to the Arizona ADAP any refund checks given to me by my elected Medicare health plan or Medicare prescription drug plan for any services paid by the Arizona ADAP. I understand this requirement applies to refund checks from a medication copay overpayment. I understand the amounts stated on the applicable refund checks from my Medicare health plan or Medicare prescription drug plan are the sole property of the Arizona ADAP. I understand I can lose my Arizona ADAP coverage if I do not submit refund checks in a timely manner. Arizona ADAP coverage can be discontinued until the amounts stated on all applicable refund checks have been received by the Arizona ADAP. Please sign the check, note “payable to ADHS” and mail to: ADAP Operations Manager 1740 W. Adams #010 Phoenix, Az. 85007 Initial: _________________
I have completely read this affidavit of understanding. By signing, I agree to the facts and conditions contained herein. Applicant signature: __________________________________ Case Manager or ADAP witness signature: _________________________________ Date signed: __________________________________
References: Medicare information can be found at https://www.medicare.gov/
