Your One Stop Shop
For Brokers who are in the Medicare field
Medicare is not a one size fits all. We want to make your life easier by providing tools that can be helpful for you in order to best serve your clients.
Downloadable Helpful Forms
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Updated Jan 2024 CMS 40B (includes employment info, but you still need to submit CMS L564 (also referred as CMS-R-297 if applicable)
CMS 40B (Part B Form)
CMS 40B fillable PDF
CMS L564- Request for employment information (form employer needs to fill out showing the member had creditable coverage if past the age of 65)SSA Locator if faxing in
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CMS 1696
This authorizes an individual to make any request; to present or to elicit evidence; to obtain appeals information; and to receive any notice in connection with a claim, appeal, grievance or request -
More info & sample letter for Equitable Relief
This is an administrative process created under federal law that allows people with Medicare to request relief from the Social Security Administration (SSA) in the form of:
Immediate or retroactive enrollment into Medicare Part B, and/or
The elimination of your Part B premium penalty
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