Forms

Use this form to set up automatic monthly payment of your Part B premium directly from your bank account. This form makes sure you’ll never miss an important payment.

Use this form to appeal your IRMAA surcharge due to a “life-changing event” such as work stoppage / reduction, loss of income-producing property, and many other reasons.

Use this form to request coverage of certain GLP-1 medications such as Wegovy or Zepbound for weight reduction when you don’t have a qualifying health condition that Medicare Part D already covers for these drugs. This form must be completed by your prescribing doctor.

Use this form to apply for Medicare Part B which is coverage for Medical Insurance. This forms gets the process started for you and by filling it our during the correct timeframes, you will avoid penalties.

Use this form to request an adjustment to your current rate of withholding to recover your overpayment because you are unable to meet your necessary living expenses.

Use this form to file a Medicare claim. Typically claims are filed automatically by your healthcare provider.

Use this form to prove group health plan coverage based on current employment. You need it to sign up for Medicare Part B during a Special Enrollment Period after you turn 65 or stop working.

Use this form to request to cancel your Medicare Part A and / or Medicare Part B coverage. This form has serious consequences and should only be used after consulting with a professional.

Use this form to file a complain to the Center for Medicare & Medicaid Services about the quality of care you received. This form ensures the Medicare program knows about any issues, so they can be resolved and improved in the future.