Authorization Agreement for Preauthorized Payments

Set up automatic monthly payment of your Part B premium directly from your bank account so you never miss a payment.

Medicare Income-Related Monthly Adjustment Amount – Life-Changing Event

Appeal your IRMAA surcharge due to a life-changing event such as work stoppage, loss of income, or other qualifying reasons.

Application for Enrollment in Medicare Part B (Medical Insurance)

Apply for Medicare Part B coverage. Filing during the correct timeframe helps you avoid late-enrollment penalties.

Request for Termination of Premium Part A, Part B, or Part B Immunosuppressive Drug Coverage

Request to cancel Medicare Part A and/or Part B coverage. This has serious consequences and should only be used after consulting a professional.

Medicare Quality of Care Complaint Form

File a complaint with the Centers for Medicare & Medicaid Services about the quality of care you received, so issues can be reviewed and improved.

Patient's Request for Medical Payment

File a Medicare claim yourself. Claims are typically filed automatically by your healthcare provider, but this form covers the times you need to file it.

Request for Employment Information

Prove you had creditable health coverage when signing up for Medicare Part B after age 65, so you avoid a late-enrollment penalty.

Request for Change in Overpayment Recovery Rate

Request an adjustment to your withholding rate to recover an overpayment because full withholding would create a financial hardship.