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You can view and print forms online by accessing the links below. Simply click on the name of the form to view or download (print) a copy.
Please call 1-800-MEDICARE (1-800-MEDICARE) for assistance filling out these forms. TTY users should call 1-877-486-2048.
All of the forms are Adobe Acrobat version 7.0.5 accessible. You will need Adobe Reader software to view the files.
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Please note that CMS Form 10106, Medicare Authorization to Disclose Personal Health Information, can be completed and printed using
Adobe Acrobat Reader. You have the ability to enter your information and then print the form to be mailed in.
If you are signing this form as a personal representative (for example, Power of Attorney) for the person with Medicare, you are attesting that you have the legal authority to sign this document on their behalf. CMS reserves the right to request copies of the documentation or you must submit the documentation upon request. If you have questions, please contact 1-800-MEDICARE (1-800-633-4227).
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Form Number
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Purpose
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Language Availability
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Medicare Authorization to Disclose Personal Health Information Note: If you live in the state of New York, please call 1-800 MEDICARE for additional instructions prior to mailing the authorization form.
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CMS-10106
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Authorizes CMS to disclose personal health information to persons or organizations that you designate. If this is for a deceased beneficiary, please Click here
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English
Spanish*
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Patient’s Request for Medical Payment |
CMS-1490S
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Used by the beneficiary to file a claim with Medicare for services and/or supplies received. Click on the link on the left to access the forms and instructions. You will need to print out both the CMS 1490S form and the applicable instructions. The address for form submission is included in the instructions.
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English
Spanish
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Medicare Appeals Form |
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Used by the beneficiary to appoint a representative, transfer appeal rights, request a hearing, request a redetermination, or request a reconsideration; depending on the situation.
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English
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*To view the Spanish version of this form, click on the 'Vea en Español' link at the top of the page.
A list of all CMS forms can be found at http://www.cms.hhs.gov/CMSForms/CMSForms/list.asp
Page Last Updated: November 24, 2008
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