MONDAY - FRIDAY: 8:00 - 6:30

CALL US  804-464-8960

MEDICARE FORMS

Below are common forms used by Medicare recipients.  Click on the PDF icon and the form will open.

Application to start Part B  CMS-40b

Use this form if you are over the age of 65, have been covered by a group health plan, and now want to start Medicare Part B.

Employer must fill out CMS-L564E

Use this form if you are over the age of 65, have been covered by a group health plan, and now want inform Social Security  / Medicare that you are losing group coverage and now qualify for a Life Event / Special Enrollment Period.

Medicare Easy Pay form

Use this form if you are not currently receiving you Social Security Income Benefit Check and would like Medicare to draft your checking account for the Medicare Part B Premium monthly payment.

IRMAA Life Event Form

Income Related Monthly Adjusted Amount (IRMAA). Use this form if you are making less in the coming year than Medicare believes you will be making and Medicare is increasing your Part B and Part D premium payments.

Form to cancel or drop Part A / Part B

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MONDAY - FRIDAY: 8:00 - 6:30 SATURDAY & SUNDAY: CLOSED

Office:  804-464-8960

Fax:  804-739-5141

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