Looking for a Medicare form?

We may just have what you are looking for. Medicare forms allow you to sign up for Medicare, to end your Medicare coverage, to dispute a payment decision, to consent to a home a visit, and more. Below you will find a variety of Medicare forms, including a Medicare appeal form, Medicare opt-out form, and Medicare complaint form. These forms and additional information can be found on the Centers for Medicare & Medicaid Services website at Medicare.gov. Once completed, review the Instructions section of the form to return the form to the appropriate government agency. The forms should not be mailed or returned to eHealth or your health plan.

For many of these Medicare forms you will need to provide your Social Security number or Medicare number, so be sure you have these numbers available. Some forms may also ask for your date of birth and address. In some cases you may be asked to provide supporting information, such as an itemized bill from a doctor’s office, outpatient hospital, or nursing home. In the case of an appeal, you may attach supporting evidence that will support your appeal. Most Medicare forms require a signature. For beneficiaries who sign by mark (X), at least one witness is required to also sign the form.

These forms can also be found on www.medicare.gov

Medicare Payment Forms

SF-5510

The form SF-5510 is to authorize the Centers for Medicare & Medicaid Services (CMS), the Federal agency that runs Medicare, to deduct your monthly Medicare premium from your bank account The form SF-5510 is to authorize the Centers for Medicare & Medicaid Services (CMS), the Federal agency that runs Medicare, to deduct your monthly Medicare premium from your bank account. read more read less

CMS-1490S

CMS Form 1490S, Patient’s Request for Medical Payment, is a claim form that you can use to request payment for Medicare Part B covered services CMS Form 1490S, Patient’s Request for Medical Payment, is a claim form that you can use to request payment for Medicare Part B covered services. The form requires your name, claim number (that is your Medicare ID number as it appears on your Medicare card), address, and a description of illness or injury for which you received treatment. read more read less

CMS-2384

Third Party Premium Billing Request

The Third Party Premium Billing Request (Form CMS 2384) is used to designate someone other than yourself to receive and pay your Medicare premium bill The Third Party Premium Billing Request (Form CMS 2384) is used to designate someone other than yourself to receive and pay your Medicare premium bill. This person could be a relative, someone who is financially responsible for you, or someone you live with. The form requires both the signature of the person enrolled in Medicare and the signature of the third party payer. If approved, your Medicare bills will be mailed to the third party and not to you. To obtain this form, please visit or contact your local Social Security Office. read more read less
Medicare Enrollment/Disenrollment Forms

CMS-40B

The form CMS-40B is used to enroll in Medicare Part B for people who already have Medicare Part A The form CMS-40B is used to enroll in Medicare Part B for people who already have Medicare Part A. If you do not have Part A, you should contact Social Security instead of completing this form. This form is sometimes used by people to sign up for Part B during their Initial Enrollment Period (IEP) when they are first eligible for Medicare. It can also be used during the General Enrollment Period (GEP) which runs January 1 through March 31, or during a a Special Enrollment Period (SEP) if you qualify for one because you had group health plan (GHP) coverage through your or your spouse’s current employment. To complete the form you will need your social security number and your current address and phone number. You will need to sign the form to confirm that you wish to sign up for Medicare Part B (medical insurance). read more read less

CMS-1763

Request for Termination of Premium Hospital And/Or Supplementary Medical Insurance

Form CMS 1763 is required to terminate your Medicare coverage Form CMS 1763 is required to terminate your Medicare coverage. This form might not be available online. You’ll need to have a personal interview with Social Security before you can terminate your Medicare coverage. To schedule your interview, please visit or contact your local Social Security Office. read more read less

CMS-L457

Acknowledgement of Request for Medicare Part B Termination

The form CMS-L457 is a notice from the Centers for Medicare & Medicaid Services that your Medical Part B medical insurance will end per your request The form CMS-L457 is a notice from the Centers for Medicare & Medicaid Services that your Medical Part B medical insurance will end per your request. The notice will state the date your coverage will end and provide you with the opportunity to change your mind. To indicate that you would like to keep your Medicare Part B insurance coverage, you must simply provide your name, social security number, address, telephone number and signature. To obtain this form, please visit or contact your local Social Security Office. read more read less

CMS-L458

Acknowledgement of Request for Medicare Part A Termination

The form CMS-L458 is a notice from the Centers for Medicare & Medicaid Services that your Part A hospital insurance will end per your request The form CMS-L458 is a notice from the Centers for Medicare & Medicaid Services that your Part A hospital insurance will end per your request. The notice will state the date your coverage will end and provide you with the opportunity to change your mind. To indicate that you would like to keep your Medicare Part A insurance coverage, you must simply provide your name, social security number, address, telephone number and signature. If you mail your form to the Social Security office before the date your coverage ends, you may be able to continue your insurance coverage without interruption. To obtain this form, please visit or contact your local Social Security Office. read more read less

CMS-43

Application for Hospital Insurance Benefits for Individuals with End Stage Renal Disease

The form CMS 43 Application for Hospital Insurance Benefits for Individuals with End Stage Renal Disease allows you to apply for both hospital (Part A) and medical (part B) insurance on the basis of being diagnosed with End Stage Renal Disease (kidney failure) The form CMS 43 Application for Hospital Insurance Benefits for Individuals with End Stage Renal Disease allows you to apply for both hospital (Part A) and medical (part B) insurance on the basis of being diagnosed with End Stage Renal Disease (kidney failure). The form asks questions about dialysis, kidney transplant and hospitalization. You must also provide employment information from the last three years. To obtain this form, please visit or contact your local Social Security Office. read more read less

CMS-L564

Form CMS L564 Request for Employment Information verifies employment and employer group health plan coverage Form CMS L564 Request for Employment Information verifies employment and employer group health plan coverage. Use this form when you want to apply for Medicare in the Special Enrollment Period that is provided to individuals who delayed enrollment in Medicare because they had group health coverage. You must have had group health plan coverage within the last eight months through your or your spouse’s employment. You complete the first half of the form with information such as the employer name and your name (applicant name) and the employer completes the second half of the form with dates of your employment and dates of your group health plan coverage. read more read less
Medicare Appeal/Claims Forms

CMS-20027

The form CMS-20027 is the Medicare Redetermination Request form for the 1st level of appeal The form CMS-20027 is the Medicare Redetermination Request form for the 1st level of appeal. The form is for if you disagree with a payment decision made on your medical claim. The form requires you to provide your name and Medicare number as well as a statement of the item or service you wish to appeal and the date the service or item was received. The one-page form also requires you to attach a copy of the initial determination notice. You must state why you do not agree with the determination decision on the claim and provide any additional information Medicare should consider. If you have evidence to submit you can attach it to the form. read more read less

CMS-20033

The Medicare form CMS 20033, Medicare Reconsideration Request Form 2nd Level of Appeal is for when you are dissatisfied with the decision that was made after completing the Medicare Redetermination Request Form- 1st level of appeal (CMS 20027) The Medicare form CMS 20033, Medicare Reconsideration Request Form 2nd Level of Appeal is for when you are dissatisfied with the decision that was made after completing the Medicare Redetermination Request Form- 1st level of appeal (CMS 20027). On this form you will explain why you do not agree with the redetermination decision on your claim and you will provide additional information that Medicare should consider. You may also attach additional evidence. read more read less

CMS-20031

The CMS 20031 Transfer of Appeal Rights allows you to transfer your right to appeal to your health-care provider The CMS 20031 Transfer of Appeal Rights allows you to transfer your right to appeal to your health-care provider. Your appeal rights are your rights to ask Medicare to reconsider a decision to not pay for an item or service you have received. If you transfer your rights, you will not be able to appeal a decision; your provider must do it for you. With this form you are not transferring all your rights, just your right to appeal for the item or service listed on the form. read more read less
Other Medicare Forms

CMS-36

Form CMS 36, Consent for Home Visit, consents to allow State or Federal health survey personnel to conduct a home visit Form CMS 36, Consent for Home Visit, consents to allow State or Federal health survey personnel to conduct a home visit. In this visit they will evaluate the quality of home health services that you receive. By consenting to this visit, you are not waiving your rights to confidentiality or privacy. To complete the form you need to provide your name and address, name of your home health agency, and your signature. read more read less

CMS-10106

The form CMS 10106 Medicare Authorization to Disclose Personal Health Information is used to inform Medicare of persons you have chosen to have access to your personal health information The form CMS 10106 Medicare Authorization to Disclose Personal Health Information is used to inform Medicare of persons you have chosen to have access to your personal health information. On the form you can decide if you want to disclose limited information or any information. You also can decide if you want Medicare to disclose the information indefinitely or for a specific period. You must provide the name and address of who you want your personal health information disclosed to. read more read less

CMS-4040

Supplementary Medicare Insurance is not the same as Medicare Supplement plans, which are sold by private companies; it is Medicare Part B Supplementary Medicare Insurance is not the same as Medicare Supplement plans, which are sold by private companies; it is Medicare Part B. Individuals who are not eligible for automatic enrollment into Medicare Part B or wish to reenroll after termination of Medicare Part B may do so using Form CMS 4040. Form CMS 4040 for Supplementary Medicare Insurance requires information such as your name, your sex, your social security number and your date of birth. There are other questions, such as if your spouse is enrolled in supplementary medical insurance. The form must be signed in ink. read more read less

CMS-10287

A Quality of Care complaint is a complaint regarding the care you received from a Medicare provider, physician and/or their staff A Quality of Care complaint is a complaint regarding the care you received from a Medicare provider, physician and/or their staff. Submit a Medicare Qualify of Care Complaint Form (CMS 10287) and a Quality Improvement Organization (QIO) under contract with Medicare is required to conduct a review of it. On the form you must provide a description of the complaint, including dates and times, persons involved and descriptions of what happened. You may contact the QIO for assistance in completing this form or for general assistance regarding your complaint. read more read less
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