Control number for this information collection is 0938-0041-2026

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The document is a form from the Department of Health and Human Services, specifically the Centers for Medicare & Medicaid Services, designed for individuals who wish to have their Medicare premiums billed to a third party. It includes sections for the enrollee's authorization, the request of the third-party payer, and space for SSA action. The form emphasizes the voluntary nature of completion while outlining necessary information for processing premium payments.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the date at the top of the form. This helps track when the request was made.
In Section I, provide your Medicare number and name as the enrollee. This identifies you in the system.
Fill in the address where you want your Medicare premium bill sent. Ensure accuracy to avoid delays.
Sign in the designated area to authorize that your premium bill be sent to a third party.
In Section II, if you are a third-party payer, complete your details including name and address.
Check applicable boxes that justify why you should receive premium notices on behalf of the enrollee.
Provide a signature and date in Section II to confirm your request as a third-party payer.

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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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