EPIC Application and Contact Information
- Download then print the EPIC Application form in English (PDF, 716KB) or
Download, use the fields in the EPIC Fill-in Application form in English then print to sign for completion (PDF, 745KB)
Important information regarding your application during the Declared Disaster Emergency in the State of New York over COVID-19.
You may begin the EPIC application process by sending in a form without completing lines 4-23. However, if your 2019 income was less than $19,140 as a single or less than $25,860 as a married couple, the information requested in lines 4-23 is required by law in order to assess your eligibility for a federal program called Extra Help. Therefore, shortly after your EPIC application has been processed, you will receive a request for this information.
Note: Lines 4-23 reflect current monthly income and are very helpful in obtaining federal assistance when your income has recently decreased below the income limits referenced above.
To learn more please:
- visit the EPIC web page EPIC and Medicare Part D,
- visit the Social Security Administration for in-depth information on Extra Help,
- visit the New York State Office for the Aging in regards to Medicare and Health Insurance, or
- contact the EPIC Helpline by phone, email or postal service as described below.
- Descargar e imprimir la aplicación de EPIC en español (PDF, 769MB)
- Other languages that the EPIC Application form is available in:
- Request an EPIC Application using the on-line Application Request Form
- Call 1-800-332-3742 (TTY 1-800-290-9138) for more information or an application
- EPIC operates a toll-free Helpline which is available from 8:30AM to 5:00PM, Monday through Friday. Call 1-800-332-3742 (TTY 1-800-290-9138) for more information or to request an application.
- You can also write to us at:
P.O. Box 15018
Albany, NY 12212-5018
- Or email us at: email@example.com.
ProblemsIf at any time you disagree with any decision affecting your enrollment in the program, you have the right to request that the issue be reviewed. This process is called a reconsideration. Some examples of decisions that you may question are:
- The disapproval of your application or renewal form;
- The amount of your income that we record to determine your eligibility or premium assistance;
- Cancellation of your EPIC coverage because you have not completed, signed and returned the Request for Additional Information form to EPIC.
You will always receive a written response to your inquiry. If you still disagree with our action, you have the right to a formal administrative hearing conducted by an independent hearing judge. This process is meant to protect your rights. You are encouraged to use it if you do not agree with a decision.
To ask for a reconsideration, you can write to the address above or call our toll-free Helpline at 1-800-332-3742. Please include your name and EPIC identification number on all letters sent to the EPIC program. This will help us respond quickly to your request.
If You Lose Your Card
If you lose your card, just call our toll-free Helpline at 1-800-332-3742 to report the loss, and we will mail you a new card.
Your EPIC Records
All EPIC records are kept strictly confidential and are maintained by EPIC in Albany. You may obtain copies of your records by writing to:EPIC
Records Access Officer
P.O. Box 15091
Albany, NY 12212-5091
If You Want To Cancel Your EPIC Coverage
To cancel your coverage you can call our toll-free Helpline at 1-800-332-3742.
Fraud And Abuse Hotline
If you think that an EPIC participant or a pharmacy is misusing or abusing the program, you can call the Fraud and Abuse Hotline by dialing toll-free 1-800-332-3742, Option #3. You will not be asked for your name or any other personal data. All calls are strictly confidential.