Medicare Forms
Click on the Medicare form you’d like to download for FREE. If you’d need our assistance to make sure you don’t make a mistake, schedule an appointment.
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.
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.
Income Related Monthly Adjustment (IRMAA) Appeal
Form SSA-44
Medicare Income-Related Monthly Adjustment Amount
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.
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 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.
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.
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 from a provider. This form lets Medicare know about any issues so they can be addressed.