Other Forms

Send the form to the company that processes your Medicare claims. To get the address, log into (or create) your secure Medicare account and view a different claim Medicare paid, or check a Medicare Summary Notice you got for another service.

• What’s the form called?
  Authorization to Disclose Personal Health Information (CMS-10106)

• What’s it used for?
  Giving Medicare permission to talk to someone you choose about your claims and health records, if you can’t.

• What’s the form called?
  Authorization Agreement for Pre-authorized Payments SF-5510
• What’sit used for?
  • Starting or stopping automatic monthly payments of your Medicare premiums through Medicare Easy Pay.
  • Changing the bank account you use for Medicare Easy Pay.

  You can also log into (or create) your secure Medicare account to set up or change recurring payments through Medicare Easy Pay.