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).

Fill out Authorization to Disclose Personal Health Information. This form is available both in English and Spanish.

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. You can also get this form in Spanish.

If you don't know the address for your carrier, you can look at "Medicare Summary Notice" (MSN). To view an electronic version of your MSN, log in to MyMedicare.gov.

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 (SF-5510) as a PDF in English or HTML in English. Get the SF-5510 as a PDF form in Spanish or HMTL form in Spanish.

Enrollment forms

I have Part A and want to apply for Part B (Application for Enrollment in Part B/CMS-40B).

Fill out the Application for Enrollment in Part B (CMS-40B). This form is available both in English and Spanish. 

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). These forms are available both in English and 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 (CMS-1696). This form is available both in English and 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 (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 (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 (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).

Visit the Forms Needed for Your Level 3 Appeal at HHS.gov and fill out the OMHA-100, the Request for Hearing by an Administrative Law Judge (ALJ) Hearing or Review of Dismissal form.