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Authorization form 2026

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The document provides information about the Medicare Easy Pay program, which allows individuals to authorize the Centers for Medicare & Medicaid Services (CMS) to automatically deduct their monthly Medicare premiums from their bank accounts. It includes instructions on how to complete the Authorization Agreement for Preauthorized Payments form (SF-5510), what information is required, where to send the completed form, and what to expect after submission. Additionally, it outlines procedures for changes in bank accounts or stopping the automatic payments.

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Click ‘Get Form’ to open it in the editor.
Begin by entering your Individual/Organization Name exactly as it appears on your Medicare card.
Input your Agency Account Identification Number, which is your Medicare number found on your card.
For Type of Payment, ensure 'Medicare Premiums' is selected; this field is prefilled for your convenience.
Locate the Nine-Digit Routing Number from the bottom left corner of a blank check and enter it accurately.
Fill in the Account Title with the name of the account holder or individual with power of attorney.
Finally, enter your Account Number without any spaces or symbols. If using a checking account, attach a voided check.

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