Form authorization 2026

1. Click ‘Get Form’ to open the Authorization Agreement for Preauthorized Payments in the editor.
2. Begin by entering the 'Agency Name' as 'Centers for Medicare & Medicaid Services'.
3. Fill in your 'Individual/Organization Name' exactly as it appears on your Medicare card.
4. Input your 'Agency Account Identification Number', which is your 11-character Medicare Number from your card.
5. Select 'Type of Payment' as 'Medicare Premiums'.
6. Provide your 'Nine-Digit Routing Number' found at the bottom left corner of your blank check.
7. Enter the 'Account Title', which is the name of the account holder for the checking or savings account.
8. Complete the 'Account Number' field without spaces or symbols, using only digits.
9. If applicable, have a bank representative sign and title in the designated area.

Start filling out your form authorization today for free and streamline your Medicare payments!