CMS-40B
Request for Enrollment in Part B
Use it when: You already have Part A and want to sign up for Part B.
Goes to: Social Security
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Getting Part B
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CMS-L564
Request for Employment Information
Use it when: You're signing up for Part B late because you had job-based coverage. Your employer fills out part of it as proof.
Goes to: Social Security
Download PDFPaying for Medicare and help with costs
SF-5510
Authorization Agreement for Pre-authorized Payments
Use it when: Set up Medicare Easy Pay so your premium is taken from your bank account each month.
Goes to: Medicare
Fill out and printSSA-44
Medicare Income-Related Monthly Adjustment Amount: Life-Changing Event
Use it when: Your income went down because of a big life change, like retiring, and you're paying IRMAA based on older, higher income.
Goes to: Social Security
Download PDFSSA-1020
Application for Extra Help with Medicare Prescription Drug Plan Costs
Use it when: You have limited income and resources and want help paying for your prescriptions.
Goes to: Social Security
Apply onlineGetting help, claims and appeals
CMS-10106
Authorization to Disclose Personal Health Information
Use it when: You want Medicare to be able to talk with a family member or someone you trust about your claims.
Goes to: Medicare
Download PDFCMS-1490S
Patient Request for Medical Payment
Use it when: Your doctor or supplier didn't file a claim with Original Medicare, so you need to file it yourself.
Goes to: Medicare
Download PDFCMS-20027
Redetermination Request
Use it when: You disagree with a coverage or payment decision from Original Medicare and want to appeal.
Goes to: Medicare
Download PDFCMS-1696
Appointment of Representative
Use it when: You want someone else, like a family member, to help with your appeal.
Goes to: Medicare
Download PDF