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Purpose. To serve as an application and recertification form for Medicare cost-sharing programs and Medicaid community-based programs, except waiver programs. (Form H1200-EZ is an optional alternative to Form H1200 and Form H1200-A for these programs.)
Find savings and support resources, including information about Lilly's Insulin Value Savings Card and LillyDirect™, an option to connect you to resources, including home delivery of your medicine.
Title: Application for Assistance – Aged and Disabled Author: Forms and Handbooks Subject: Form H1200-EZ\r\n06/2011 Created Date: 2/4/2016 9:37:09 AM
Program. (H1200-EZ) • You are applying only for a Medicare Savings Program. (H1200-EZ) • You live in a state supported living center. (H1200-PFS) • You live in a state hospital. (H1200-PFS) To ask for these forms, call 2-1-1 or 1-877-541-7905. Most phone and fax numbers on this form are free to call. If you are deaf, hard of hearing, or ...
Lilly may be able to help those patients who need additional assistance. Call the Lilly Diabetes Solution Center at . Lilly is committed to helping people with diabetes regardless of whether they have insurance from an employer, Medicare, or no insurance at all.
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If you want to apply for SNAP food benefits, cash help for families (TANF), or Medicaid for children and families, you need a different form. To get that form, call 2-1-1 (after you pick a language, press 2). Or apply online at www.YourTexasBenefits.com. Report waste, fraud, and abuse.
