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I want to make sure Medicare can give my personal health information to someone other than me.
Fill out the Authorization to Disclose Personal Health Information form (CMS-10106).
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I want to file a claim for services and/or supplies that I got.
Fill out the Patient Request for Medical Payment form (CMS-1490S). Follow the instructions on the second page to submit the form to your carrier. If you don't know the address for your carrier, you can find it here.
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I want to start, stop, or change bank accounts for automatic monthly deductions of my Medicare premium.
Fill out the Authorization Agreement for Pre-authorized Payments form (SF-5510).
Appeals forms
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I want to appoint a representative to help me file an appeal.
Fill out the Appointment of Representative form (CMS-1696).
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I want to transfer my appeal rights to my provider or supplier.
Fill out the Transfer of Appeal Rights form (CMS-20031).
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I want to request an appeal (redetermination) because I disagree with a coverage or payment decision from Medicare (1st level of the appeals process).
Fill out the Redetermination Request form (CMS-20027).
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I want to request a reconsideration because I’m not satisfied with the decision made during the 1st level of my appeal.
Fill out the Medicare Reconsideration Request form (CMS-20033).
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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.
Fill out the Request for Hearing by an Administrative Law Judge form (CMS-20034A/B).
Get a list of all Medicare forms.
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