Enrollment Forms
CMS-40B – Application for Enrollment in Part B
What’s it used for? Signing up for Part B when you already have Part A.
CMS-L564 – Request for Employment Information
What’s it used for? Giving the Social Security Administration proof you’re eligible to sign up for Part B if:
- You’re still working.
- You retired within the last 8 months.
- You lost job-based health coveraged within the last 8 months.
To sign up for Part B in one of these situations, you’ll also need to fill out and submit an Application for Enrollment in Part B (CMS-40B) form at the same time, which you can find linked above.
CMS-10797 – Application for Medicare Part A & Part B using a Special Enrollment Period
What’s it used for? Signing up for Part A & Part B if you meed the criteria for a Special Enrollment Period.
Which situations qualify for an exceptional conditions Special Enrollment Period?
You can sign up for Part B (and Premium-Part A) without paying a late enrollment penalty, using an “exceptional conditions” Special Enrollment Period if you:
- Lost Medicaid coverage on or after 1/1/2023.
- Missed a chance to sign up because you were impacted by a natural disaster or an emergency that’s declared or starts on or after 1/1/2023 (or if your authorized representative, legal guardian, or caregiver was impacted by a disaster or emergency).
- Missed a chance to sign up because you got inaccurate or misleading information from your health plan or employer on or after 1/1/2023.
- Were released from incarceration on or after 1/1/2023 (and missed a chance to sign up while you were incarcerated).
- Missed a chance to sign up because you experienced other exceptional conditions. You must contact Social Security to ask for this Special Enrollment Period.
To sign up for Medicare in one of these situations, fill out form CMS-10797 and send the completed form to your local Social Security office by fax or mail.
CMS-10798 – Application for Enrollment in Part B Immunosuppressive Drug Coverage
What’s it used for? Signing up for the Part B Immunosuppressive Drug benefit.
Appeals Forms
CMS-20027 – Redetermination Request
What’s it used for? Requesting an appeal (redetermination) if you disagree with Medicare’s coverage or payment decision.
CMS-20033 – Medicare Reconsideration Request
What’s it used for? Requesting a 2nd appeal (reconsidersation) if you’re not satisfied with the outcome of your first appeal.
OMHA-100 – Request for Administrative Law Judge Hearing or Review of Dismissal
What’s it used for? Requesting a hearing by an Administrative Law Judge (ALJ) if you’re not satisfied with the outcome of your 2nd appeal.
Additional forms for your Level 3 appeal can be found here: https://www.hhs.gov/about/agencies/omha/filing-an-appeal/forms/index.html
CMS-1696 – Appointment of Representative
What’s it used for? Giving another person legal permission to help you file an appeal.
CMS-20031 – Transfer of Appeal Rights
What’s it used for? Transferring your appeal rights to your provider or supplier so they can file an appeal if Medicare decides not to pay for an item or service.
Other Forms
CMS-1490S – Patient Request for Medical Payment
What’s it used for? Filing a claim when you get services or supplies (if your provider doesn’t file it).
CMS-10106 – Authorization to Disclose Personal Health Information
What’s it used for? Giving Medicare permission to talk to someone you choose about your claims and health records.
SF-5510 – Authorization Agreement for Pre-authorized Payments
What’s it used for? Starting or stopping automatic payments of your Medicare premiums through Medicare Easy Pay or changing the bank account you use for Medicare Easy Pay.
