Medicare Forms and Information


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Authorization to Disclose Protected Health Information (PHI) Form 
Automates Premium Payment (ACH) Form 
CMS Appointment of Representative Direct Member Reimbursement Form 
Mail-Order Physician New Prescription Fax Form 
Medicare Part B vs. Part D Form 
Notice of Privacy Practices 
Pharmacy Mail-Order Form 
Prescription Drug Claim Form 



This information is available for free in other languages. Please call our Customer Service number at 1-888-285-2249. (TTY/TDD users should call 711). We are open between 8 a.m. and 8 p.m., local time, 7 days a week. If you are calling from February 15 through September 30, alternate technologies (for example, voicemail) will be used on the weekends and holidays.

Esta información está disponible en otros idiomas de forma gratuita. Comuníquese a nuestro número de Servicio al Cliente llamando al 1-888-285-2249. (Los usuarios de TTY/TDD deberán llamar al 711). Nuestro horario es de 8 a.m. a 8 p.m., hora local, los 7 días de la semana. Si usted llama del 15 de febrero al 30 de septiembre, durante los fines de semana y feriados, se usarán tecnologías alternas (por ejemplo, correo de voz).

Contact Medicare for more information about benefits and services, including general information about Medicare prescription drug plan coverage.

Call

1-800-MEDICARE (1-800-633-4227) 24 hours a day, 7 days a week.

If you are hearing or speech impaired, please call 1-877-486-2048.

Web

www.medicare.gov

If you would like to submit feedback directly to Medicare, please use the Medicare Compliant Form or contact the Office of the Medicare Ombudsman .