Useful Forms
Click below on which form you’d like to download for FREE. Contact FSA Health for additional assistance and advice.
Form SF-5510
Authorization Agreement for Preauthorized Payments
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.
Form CMS-L564
Authorization Agreement for Preauthorized Payments
Use this form to prove you had creditable health insurance when you sign up for Medicare Part B after age 65. This form makes sure you don’t get a Part B penalty for having a gap in coverage.
Form SSA-44
Medicare Income-Related Monthly Adjustment Amount – Life-Changing Event
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.
Form SSA-40B
Application for Enrollment in Medicare Part B (Medical Insurance)
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.
Form CMS-1763
Request For Termination Of Hospital and / or Supplementary Medical Insurance
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.
Form CMS-10287
Medicare Quality of Care Complaint Form
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.