Medicare Forms

1. Medicare Authorization to Disclose Personal Health Information (CMS-10106)

Authorizes CMS to disclose personal health information to persons or organizations that you designate.

2. Patient's Request for Medical Payment (CMS-1490S)

Used by the beneficiary to file a claim with Medicare for services and/or supplies received.

Click on the link on the left to access the forms and instructions. You will need to print out both the CMS 1490S form and the applicable instructions. The address for form submission is included in the instructions.

3. Medicare Appeals Form

Used by the beneficiary to appoint a representative, transfer appeal rights, request a hearing, request a redetermination, or request a reconsideration; depending on the situation.

4. Online Medicare Application

Used to sign up for Medicare. You can apply for Medicare even if you are not ready to retire. You can use the online Medicare application if you:

  • are at least 64 years and 8 months old;
  • want to sign up for Medicare;
  • do not want to start receiving Social Security Benefits in the next four months; and
  • ive in the United States, or one of its territories or commonwealths.

A list of all CMS forms can be found at Centers for Medicare and Medicaid Services