If you just want to see the application form, you can view a sample at www.socialsecurity.gov/prescriptionhelp.  Instruction sheets are available in 15 different languages to help you understand the English application.

If you wish to apply for help with Medicare prescription drug costs, Social Security recommends that you use their online application at www.socialsecurity.gov/i1020/

If you prefer not to fill out this application on the Internet, you can call the Social Security Administration’s toll-free number, 1-800-772-1213 for a paper application or to make an appointment for application.. If you are deaf or hard of hearing, call the Social Security Administration’s toll-free TTY number, 1-800-325-0778. Representatives are available Monday through Friday from 7 a.m. to 7 p.m. Tell the representative that you want to apply for help with Medicare prescription drug costs.