Forms
Please select the form you wish to download for free below. If you require assistance to ensure accuracy and avoid mistakes, feel free to schedule an appointment with us.
Scope of Appointment Form
By signing this form, you agree to a meeting with a sales agent to discuss the types of products you initialed above.
Permission Slip
Application for Enrollment in Medicare Part B
Please fill this form out to apply for Medicare Part B. Don’t forget your CMS – L564 Employer form turn then both to Social Security to wave Part B penalty.
Form CMS 40-B
Application for Enrollment in Medicare Part B (Medical Insurance)
Income Related Monthly Adjustment (IRMAA) Appeal
Use this form to appeal your IRMAA surcharge due to a “life-changing event,” such as work stoppage/reduction, loss of income-producing property, among other qualifying reasons.
Form SSA-44
Medicare Income-Related Monthly Adjustment Amount – Life-Changing Event
Enroll in Medicare Easy Pay - Automatic Premium Withdrawal
Please utilize this form to establish automatic monthly payment of your Part B premium from your bank account, ensuring you never miss a payment.
Form SF-5510
Authorization Agreement for Preauthorized Payments
File A Complaint About The Quality of Healthcare You Received
Use this form to lodge a complaint with the Center for Medicare & Medicaid Services regarding the quality of care you received. This ensures that any issues are brought to Medicare’s attention for resolution and future improvement.
Form CMS-10287
Medicare Quality of Care Complaint Form
File A Medicare Claim
Please complete this form to file a Medicare claim. Although claims are usually submitted automatically by your healthcare provider, you can use this form if necessary.
Form CMS-1490S
Patient’s Request For Medical Payment
Request for Change in Overpayment Recovery Rate
Form SSA-634
Request for Change in Overpayment Recovery Rate
