The form CMS-40B is used to enroll in Medicare Part B for people who already have Medicare Part A. If you do not have Part A, you should contact Social Security instead of completing this form. This form is sometimes used by people to sign up for Part B during their Initial Enrollment Period (IEP) when they are first eligible for Medicare. It can also be used during the General Enrollment Period (GEP) which runs January 1 through March 31, or during a a Special Enrollment Period (SEP) if you qualify for one because you had group health plan (GHP) coverage through your or your spouse’s current employment. To complete the form you will need your social security number and your current address and phone number. You will need to sign the form to confirm that you wish to sign up for Medicare Part B (medical insurance). read more

Form CMS 1763 is required to terminate your Medicare coverage. This form might not be available online. You’ll need to have a personal interview with Social Security before you can terminate your Medicare coverage. To schedule your interview, please visit or contact your local Social Security Office. read more

The form CMS-L457 is a notice from the Centers for Medicare & Medicaid Services that your Medical Part B medical insurance will end per your request. The notice will state the date your coverage will end and provide you with the opportunity to change your mind. To indicate that you would like to keep your Medicare Part B insurance coverage, you must simply provide your name, social security number, address, telephone number and signature. To obtain this form, please visit or contact your local Social Security Office. read more

The form CMS-L458 is a notice from the Centers for Medicare & Medicaid Services that your Part A hospital insurance will end per your request. The notice will state the date your coverage will end and provide you with the opportunity to change your mind. To indicate that you would like to keep your Medicare Part A insurance coverage, you must simply provide your name, social security number, address, telephone number and signature. If you mail your form to the Social Security office before the date your coverage ends, you may be able to continue your insurance coverage without interruption. To obtain this form, please visit or contact your local Social Security Office. read more

The form CMS 43 Application for Hospital Insurance Benefits for Individuals with End Stage Renal Disease allows you to apply for both hospital (Part A) and medical (part B) insurance on the basis of being diagnosed with End Stage Renal Disease (kidney failure). The form asks questions about dialysis, kidney transplant and hospitalization. You must also provide employment information from the last three years. To obtain this form, please visit or contact your local Social Security Office. read more

Form CMS L564 Request for Employment Information verifies employment and employer group health plan coverage. Use this form when you want to apply for Medicare in the Special Enrollment Period that is provided to individuals who delayed enrollment in Medicare because they had group health coverage. You must have had group health plan coverage within the last eight months through your or your spouse’s employment. You complete the first half of the form with information such as the employer name and your name (applicant name) and the employer completes the second half of the form with dates of your employment and dates of your group health plan coverage. read more

The form CMS-20027 is the Medicare Redetermination Request form for the 1st level of appeal. The form is for if you disagree with a payment decision made on your medical claim. The form requires you to provide your name and Medicare number as well as a statement of the item or service you wish to appeal and the date the service or item was received. The one-page form also requires you to attach a copy of the initial determination notice. You must state why you do not agree with the determination decision on the claim and provide any additional information Medicare should consider. If you have evidence to submit you can attach it to the form. read more

The Medicare form CMS 20033, Medicare Reconsideration Request Form 2nd Level of Appeal is for when you are dissatisfied with the decision that was made after completing the Medicare Redetermination Request Form- 1st level of appeal (CMS 20027). On this form you will explain why you do not agree with the redetermination decision on your claim and you will provide additional information that Medicare should consider. You may also attach additional evidence. read more

The CMS 20031 Transfer of Appeal Rights allows you to transfer your right to appeal to your health-care provider. Your appeal rights are your rights to ask Medicare to reconsider a decision to not pay for an item or service you have received. If you transfer your rights, you will not be able to appeal a decision; your provider must do it for you. With this form you are not transferring all your rights, just your right to appeal for the item or service listed on the form. read more