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Useful Forms
Enroll in Medicare Easy Pay - Automatic Premium Withdrawal
Form SF-5510
Authorization Agreement for Preauthorized Payments
Set up automatic monthly payments for your Part B premium using this form—it’s the easiest way to make sure you never miss a payment!
Proof of Creditable Coverage When Applying for Medicare
Form CMS-L564
Authorization Agreement for Preauthorized Payments
Use this form to confirm you had creditable health insurance before signing up for Medicare Part B after age 65—so you won’t get a penalty for a gap in coverage.
Income Related Monthly Adjustment (IRMAA) Appeal
Form SSA-44
Medicare Income-Related Monthly Adjustment Amount – Life-Changing Event
Had a major change in your life, like job loss or reduced income? Use this form to appeal your IRMAA surcharge and explain your “life-changing event.”
Application For Enrollment in Medicare Part B
Form SSA-40B
Application for Enrollment in Medicare Part B
(Medical Insurance)
Use this form to apply for Medicare Part B—your medical insurance coverage. Submitting it at the right time helps you avoid any late enrollment penalties.
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 cancel your Medicare Part A or Part B coverage—but be careful! Canceling can have serious effects, so it’s best to speak with a professional first.
File A Complaint About The Quality of Healthcare You Received
Form CMS-10287
Medicare Quality of Care Complaint Form
Use this form to share your concerns about the quality of care you received with Medicare. Your feedback helps improve services for everyone.
File A Medicare Claim
Form CMS-1490S
Patient’s Request For
Medical Payment
Use this form to submit your Medicare claim. Usually, your doctor or healthcare provider takes care of this for you.
Request for Change in Overpayment Recovery Rate
Form SA-634
Request for Change in Overpayment Recovery Rate
Use this form to ask for a change to your current withholding rate if you’ve overpaid and need the funds to cover essential living expenses.