Medicare Intake Form

For fastest service, click here to fill out my Medicare intake form

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Leaving Employer Group Health (Delayed Part B Enrollment)

CMS-L564E (Employer HR Completes)

CMS40B-E (Employee Completes)

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Other Medicare-Related Forms

CMS-18F5 (Apply for Medicare Part A)

Part D Late Enrollment Penalty (LEP) Reconsideration Request Form

SSA-44 IRMAA Appeal

SSA-561 Request for Reconsideration

CMS-1490 (Submit claim directly to Medicare)

Generic Scope of Appointment (download)

Generic Scope of Appointment (online)

Letter of Equitable Relief

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