Medicare forms

To get the Medicare form you need, find the situation that applies to you. Get forms in alternate formats.

I want to make sure Medicare can give my personal health information to someone other than me (Authorization to Disclose Personal Health Information form/CMS-10106).
I want to file a claim for services and/or supplies that I got (Patient Request for Medical Payment form/CMS-1490S).

Fill out the Patient Request for Medical Payment form (CMS-1490S).You'll find the address for form submission in the instructions. Follow the instructions on the second page to submit the form to your carrier. Get this form in Spanish.

If you don't know the address for your carrier, you can:

I want to start, stop, or change bank accounts for automatic monthly deductions of my Medicare premium (Authorization Agreement for Pre-authorized Payments form/SF-5510).

Fill out the Authorization Agreement for Pre-authorized Payments form [PDF, 117 KB] (SF-5510). Get this form in Spanish.

Enrollment forms

I have Part A and want to apply for Part B (Application for Enrollment in Part B/CMS-40B).
I want to sign up for Part B while I’m employed or during the 8 months after employment or my employer/union coverage has ended, and I need to provide employment information (Request for Employment Information/CMS-L564).

Fill out an Application for Enrollment in Part B (CMS-40B) and a Request for Employment Information (CMS-L564). Get the Application for Enrollment in Part B (CMS-40B) in Spanish. Get the Request for Employment Information (CMS-L564) in Spanish.

Appeals forms

I want to appoint a representative to help me file an appeal (Appointment of Representative form/CMS-1696).

Fill out the Appointment of Representative form [PDF, 47.7 KB] (CMS-1696). Get this form in Spanish.

I want to transfer my appeal rights to my provider or supplier (Transfer of Appeal Rights form/CMS-20031).
Fill out the Transfer of Appeal Rights form [PDF, 36.2 KB] (CMS-20031).
I want to request an appeal (redetermination) because I disagree with a coverage or payment decision from Medicare (1st level of the appeals process) (Redetermination Request form/CMS-20027).
Fill out the Redetermination Request form [PDF, 100 KB] (CMS-20027).
I want to request a reconsideration because I’m not satisfied with the decision made during the 1st level of my appeal (Medicare Reconsideration Request form/CMS-20033).
Fill out the Medicare Reconsideration Request form [PDF, 180 KB] (CMS-20033).
I want to request a hearing by an Administrative Law Judge (ALJ) because I’m not satisfied with the decision made during the 2nd level of my appeal (Request for Administrative Law Judge (ALJ) Hearing or Review of Dismissal form/OMHA-100).