Forms to Download
Download these forms for free as needed. If you would like assistance or ensure that you do not make a mistake, schedule an appointment to talk or use the form on right to message us directly.
Enroll In Medicare Easy Pay- Automatic part B Withdraw
Use this form to set up automatic payments for your Part-B premium directly from your bank account.
Proof of Creditable Coverage When Applying for Medicare
If you sign up for Medicare Part-B after age 65, use this form to show that you had creditable coverage. Without this, you may face penalties due to a coverage gap.
IRMAA Appeal Form
If you have a life changing event, such as stopping or reducing work, loss of income, or other reasons, use this form to request a change to your IRMAA suchage.
Medicare Part-B Enrollment Form
Use this form to apply for Medicare Part-B. By filling this out during the correct timeframe, you can avoid penalties.
Application for Termination of Medicare Part-A or Part-B
Use this form to cancel your Medicare Part-A or Part-B coverage. This form should only be used after consulting with a professional as it has serious consequences.
Filing A Complaint About the Quality of Healthcare You Received
Use this form to file a complaint with the Center for Medicare & Medicaid Services.
File a Medicare Claim
Typically, claims are filed automatically by your healthcare provider. If something is missed however, you can use this form.
Application for Medicare Special Enrollment Period under Exceptional Conditions
Use this form to sign up for Medicare Part-B without paying a late enrollment penalty by using an ‘exceptional conditions’ SEP. Conditions apply.
File an Appeal with Original Mediacre
Use for 20027 to file a level 1 appeal with Original Medicare.