Control number for this information collection is 0938-0041-2025

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4.5 out of 5

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The document is a Third Party Premium Billing Request form from the Department of Health and Human Services, specifically for Medicare and Medicaid services. It allows individuals to authorize a third party to receive and pay their Medicare premium bills. The form includes sections for the enrollee's information, the third party's request, and a privacy statement regarding the use of provided information.

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Versions	Form popularity	Fillable & printable
2018	4.5 Satisfied (37 Votes)
2003	4.9 Satisfied (57 Votes)

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