Please review this picture of the medicare card 2025

1. Click ‘Get Form’ to open it in the editor.
2. In Section I, indicate if you are currently enrolled in Medicare Part A or Part B by selecting 'Yes' or 'No'. If 'Yes', proceed to fill in your Full Name as it appears on your Medicare card.
3. Enter your Medicare Claim Number and Social Security Number if the Claim Number is unavailable. Don't forget to include your Date of Birth in the format (Mo/Day/Year) and select your sex.
4. In Section II, print your Claimant Name and Claim Number. If someone else is completing this form for you, provide their name and signature along with the date.
5. If you choose not to provide information in Sections I and II, move to Section III. Print your Claimant Name and Claim Number, then state your reasons for refusal before signing and dating the form.

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