Forms

We’ve compiled the most commonly used documents below.

Application to Start Medicare Part B Form CMS-40B - Use this form if you are over the age of 65, have been covered by a group health plan, and now want to start Medicare Part B.

Employer Must Fill Out Form CMS-L564 – Use this form if you are over the age of 65, have been covered by a group health plan, and now want to inform Social Security  / Medicare that you are losing group coverage and now qualify for a Life Event / Special Enrollment Period.

IRMAA (Income Related Monthly Adjustment Amount Form CMS SSA-44– Income Related Monthly Adjusted Amount (IRMAA). Use this form if you are making less in the coming year than Medicare believes you will be making and Medicare is increasing your Part B and Part D premium payments.

IRMAA Sheet to determine Part B monthly premium

Statement of Claimant Form CMS SSA-795 – If the CMS Form L564 can’t be obtained from employer, use this form to verify compliant health coverage

Patient’s Request for Medical Payment Form CMS 1490S – Patient is requesting payment for services rendered from medicare

Part D (Drug) Late Enrollment Penalty (LEP) Reconsideration Request Form CMS 1696 – Use this form to request the LEP be eliminated due to having compliant drug coverage.