Medicare.gov

Other Forms

File a claim

  • What’s the form called?
    Patient Request for Medical Payment (CMS-1490S)
  • What’s it used for?
    Filing a claim when you get services and/or supplies (if your provider doesn’t file it).
Send the form to the company that processes your Medicare claims. To get the address, log into (or create) your secure Medicare account and view a different claim Medicare paid, or check a Medicare Summary Notice you got for another service.


Allow Medicare to share your health information

  • What’s the form called?
    Authorization to Disclose Personal Health Information (CMS-10106)
  • What’s it used for?
    Giving Medicare permission to talk to someone you choose about your claims and health records, if you can’t.


Set up or change recurring premium payments

  • What’s the form called?
    Authorization Agreement for Pre-authorized Payments SF-5510

  • What’s it used for?

    • Starting or stopping automatic monthly payments of your Medicare premiums through Medicare Easy Pay.
    • Changing the bank account you use for Medicare Easy Pay.
You can also log into (or create) your secure Medicare account to set up or change recurring payments through Medicare Easy Pay.