Medicare related forms from the Dept. of the Treasury, Social Security Administration, and Centers for Medicare and Medicaid

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Enroll in Medicare Easy Pay - Automatic Premium Withdrawal

Form SF-5510

Authorization Agreement for Preauthorized Payments

Use this form to set up automatic monthly payment of your Part B premium directly from your bank account. This form makes sure you’ll never miss an important payment. 

Download SF-5510

Application For Enrollment in Medicare Part B

Form CMS-40B

Application for Enrollment in Medicare Part B (Medical Insurance)

Use this form to apply for Medicare Part B which is coverage for Medical Insurance. This forms gets the process started for you and by filling it our during the correct timeframes, you will avoid penalties. 

Download CMS-40B

File A Medicare Claim

Form CMS-1490S

Patient’s Request For Medical Payment

Use this form to file a Medicare claim.

Download CMS-1490S

Medicare Forms

Proof of Creditable Coverage When Applying for Medicare

Form CMS-L564

Authorization Agreement for Preauthorized Payments

Use this form to prove you had creditable health insurance when you sign up for Medicare Part B after age 65. This form makes sure you don’t get a Part B penalty for having a gap in coverage.

Download CMS-L564

Application For Termination of Medicare Part A and/or Part B

Form CMS-1763

Request For Termination Of Hospital and / or Supplementary Medical Insurance

Use this form to request to cancel your Medicare Part A and / or Medicare Part B coverage. This form has serious consequences and should only be used after consulting with a professional.

Download CMS-1763

Request for Change in Overpayment Recovery Rate

Form SSA-634

Request for Change in Overpayment Recovery Rate

Use this form to request an adjustment to your current rate of withholding to recover your overpayment because you are unable to meet your necessary living expenses. 

Download SSA-634

Income Related Monthly Adjustment (IRMAA) Appeal

Form SSA-44

Medicare Income-Related Monthly Adjustment Amount – Life-Changing Event

Use this form to appeal your IRMAA surcharge due to a “life-changing event” such as work stoppage / reduction, loss of income-producing property, and many other reasons. 

Download SSA-44

File A Complaint About The Quality of Healthcare You Received

Form CMS-10287

Medicare Quality of Care Complaint Form

Use this form to file a complain to the Center for Medicare & Medicaid Services about the quality of care you received. This form ensures the Medicare program knows about any issues, so they can be resolved and improved in the future.

Download CMS-10287