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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
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
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
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 (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
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
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
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.
© 2023 The Medicare Family. All Rights Reserved.
Owned by: ESG Insurance LLC. This website is not connected with the federal government or the federal Medicare program. The purpose of this website is the solicitation of insurance. We do not offer every plan available in your area. Currently we represent 31 organizations which offer 3,740 products. Please contact Medicare.gov or 1-800 MEDICARE or your local State Health Insurance Program to get information on all of your options.
© 2024 The Medicare Family. All Rights Reserved.
Owned by: ESG Insurance LLC. This website is not connected with the federal government or the federal Medicare program. The purpose of this website is the solicitation of insurance. We do not offer every plan available in your area. Currently we represent 31 organizations which offer 3,740 products. Please contact Medicare.gov or 1-800 MEDICARE or your local State Health Insurance Program to get information on all of your options.
© 2024 The Medicare Family. All Rights Reserved.
Owned by: ESG Insurance LLC. This website is not connected with the federal government or the federal Medicare program. The purpose of this website is the solicitation of insurance. We do not offer every plan available in your area. Currently we represent 31 organizations which offer 3,740 products. Please contact Medicare.gov or 1-800 MEDICARE or your local State Health Insurance Program to get information on all of your options.
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