Form 2378M, Mail-In Application for Payment of Medicare Premiums, Deductibles and Coinsurance Revised

Form 2378M, Mail-In Application for Payment of Medicare Premiums, Deductibles and Coinsurance Revised

Summary:

• Form 2378M (pdf)/2378MS (pdf), Mail-In Application for Payment of Medicare Premiums, Deductibles and Coinsurance, has been revised.
• This application is fillable and may be completed online. 
• The application may be downloaded at  http://www.hfs.illinois.gov/medicalforms or ordered from the warehouse.