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Required Forms

New to Medicare? Leaving employer coverage? Wondering what to do about your HSA? Re-enrolling in or terminating Medicare coverage? Wondering how to set up a Medicare.gov account? We have you covered.

50

States Served

100+

Professional agents

40+

Years in Medicare

50+

Insurance plans offered

Turning 65?

Below are the applications you’ll need to enroll in Medicare for the first time, apply for subsidies, and/or maintain coverage if anything changes.

Or call our office for assistance: 1 (888) 467-4811.

Apply for Retirement, Spouse, or Medicare Benefits Apply Now

Get Help With Medicare Prescription Drug Costs Submit Online

Change of Address or Telephone Number Change Here

Leaving Group Health?

If you have Medicare Part A only, you will need the 2 following forms to activate your Medicare Part B. Once you have both forms completed, you can send them to your local Social Security office or email one of our Senior Account Managers directly and they will upload them straight to Social Security for you. If you have an HSA Group Health Plan, a third form will be required so you will not receive penalty (see below regarding HSA form).

Medicare Part B Activation Request CMS - 40B

Employer Verification CMS - L564

Need to cancel Medicare? – over 65

This is a form that needs to be completed and sent or uploaded to Social Security in order to cancel Medicare Part A or Part B.

Request for Termination of Medicare A and/or B

CMS - 1763

Returning to Group Health – over 65

When returning to an employer group plan, sometimes canceling Medicare can be tricky. It is encouraged to speak with an advisor before you cancel Medicare. You may be advised to keep Part A or B or both. Below is the form you need to cancel Medicare A or B.