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Wednesday, April 23, 2014
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Forms

adobe_acrobat.gifThe following forms are available in PDF format, so you will need Adobe Acrobat Reader to view them. If you do not have Acrobat Reader, you can download it for free from Adobe by clicking the link to the left.

Authorized Representative Form: Due to HIPAA Privacy Practices, SPDAP requires that anyone attempting to act as a representative for a member or an applicant must be on file as an Authorized Representative. For a copy of the Authorized Representative Form, please click here.

NOTE: Only one authorized representative is preferred per member or applicant.

Income Determination Worksheet: If you are trying to determine if you or a loved one may be eligible for the Maryland Senior Prescription Drug Assistance Program, you may use our Income Determination Worksheet as a guideline. For a copy of this form, please click here.

NOTE: While this form will be a good indicator of your financial eligibility, the SPDAP Enrollment Staff will review your application to determine if you are eligible.

Enrollment Application: For a copy of the SPDAP Enrollment Application, please click here.

  


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