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Useful Forms

If you’re a “do it yourself” sort of person, download one of the Medicare and Social Security forms below. If you’d like our assistance to make sure you don’t make a mistake, schedule an appointment.

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. 

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 – 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. 

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. This form ensures the Medicare program knows about any issues, so they can be resolved and improved in the future.

File A Medicare Claim

Form CMS-1490S

Patient’s Request For Medical Payment

Use this form to file a claim.