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 Medicare Part B Employer Form
Please turn this into your employer to sign then turn this form into Social Security along with the CMS 40-B Part B application form to wave Part B penalty.
Form CMS-L564
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)
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
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.
Form SSA-634 Request for Change in Overpayment Recovery Rate
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
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