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.
Form CMS-L564 (pdf)
DownloadIncome 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.
Form SSA-44 (pdf)
DownloadApplication 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.
Form SSA-40B (pdf)
DownloadEnroll 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.
Form SF-5510 (pdf)
DownloadCMS - Scope of Appointment
Form MED-136
Authorization for Agent to discuss types of Medicare products
Scope of Appointment (pdf)
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