G 740s 2026

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Click ‘Get Form’ to open it in the editor.
Begin by entering your name exactly as it appears on your Medicare card in Item 1.
In Item 2, input your Claim Number as shown on your Medicare card and indicate your gender.
For Item 3, provide your full mailing address, including any apartment number if applicable.
In Item 4, describe the illness or injury for which you received treatment and check the appropriate boxes regarding employment or accident-related issues.
Complete Items 5a-c by answering questions about other health coverage and providing necessary details if applicable.
Sign and date the form in Item 6. If unable to sign, follow the instructions provided for a witness signature.

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