Useful Medicare Forms

Click below on which form you’d like to download for FREE. If you’d like our assistance to make sure you don’t make a mistake, schedule an appointment.

Form SF-5510

Enroll in Medicare Easy Pay - Automatic Premium Withdrawal

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.

Form CMS-L564

Proof of Creditable Coverage When Applying for Medicare

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.

Form SSA-44

Income Related Monthly Adjustment (IRMAA) Appeal

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.

Form SSA-40B

Application For Enrollment in Medicare Part B

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.

Form CMS-1763

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

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.

Form CMS-10287

File A Complaint About The Quality of Healthcare You Received

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.

Form CMS-1490S

File A Medicare Claim

Patient’s Request For Medical Payment

Use this form to file a Medicare claim. Typically claims are filed automatically by your healthcare provider.

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.