Form Authorization – Fill Out and Use This PDF

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services

7500 Security Boulevard Baltimore, Maryland 21244-1850

Thank you for your interest in Medicare Easy Pay. By completing and returning

the Authorization Agreement for Preauthorized Payments form (SF-5510), you’re authorizing the Centers for Medicare & Medicaid Services (CMS), the Federal agency that runs the Medicare program, to deduct your monthly Medicare premium from your bank account. This notice tells you what happens once you complete and return the form.

What information do I need to put on the form?

The form asks for basic information about you and your bank (also called a financial institution). Have your red, white, and blue Medicare card and a blank check from

your bank account with you when you fill out the form.

Here are some tips to help you complete the form:

•The “Agency Name” should be “Centers for Medicare & Medicaid Services”.

•The “Individual/Organization Name” is your name the way it looks on your Medicare card.

•Your “Agency Account Identification Number” is your 11-character Medicare Number from your Medicare card.

•The “Type of Payment” should be “Medicare Premiums”.

•Your “Nine-Digit Routing Number” is the number from the bottom left corner of your check.

•The “Account Title” is the name of the checking or savings account holder.

•The “Account Number” is the checking or savings account number (don’t use spaces or symbols).

•The “Signature and Title of Representative” should be completed only if someone at your bank helps you complete the form.

If you’re using a checking account to pay your premiums, attach a blank, voided check. We’ll use it to validate the Routing and Account numbers you provided on the form.

Where do I send the completed form?

Centers for Medicare & Medicaid Services

Medicare Premium Collection Center

P.O. Box 979098

St. Louis, MO 63197-9000

What happens once I return this form?

We’ll process your form once we get it. Sometimes this can take 6 to 8 weeks. If we can’t process your form, we’ll return the form to you with a letter explaining why.

Once your form is successfully processed, your Medicare Premium Bills (form CMS-500) will state “THIS IS NOT A BILL” in the upper right corner, indicating that your automatic deductions should begin. Until then, you must pay your Medicare premiums another way. (Visit Medicare.gov for more information on ways to pay your premiums.)

How do automatic bank deductions work?

We’ll deduct your premiums from your bank account, usually on the 20th of each month. It will appear on your bank statement as a “CMS Medicare Premium” Automated Clearing House (ACH) transaction. Your initial ACH deduction can be up to 3 months’ premiums. After the initial deduction, 1 month’s premiums plus $10 is the maximum deduction each month.

If you owe more than these limits, we won’t be able to deduct your premiums. Once the amount you owe is within the limits, your automatic deductions can begin. Until then, you must pay your Medicare premiums another way.

We’ll only try to deduct your premiums once each month. If your bank rejects or returns your premiums deduction, we’ll send you a letter with instructions on other ways to pay your premiums.

Do I need to do anything when my premium rate changes?

No, we’ll automatically deduct the new premium amount from your bank account.

What if I want to change bank accounts or stop Medicare Easy Pay?

Complete another Authorization Agreement for Preauthorized Payments form (SF-5510), and indicate the type of change you want to make on the form. Mail the completed form to the address above. It can take 6 to 8 weeks to change your bank account. You can get a new form at Medicare.gov or by calling 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877- 486-2048.

You have the right to get Medicare information in an accessible format, like large print, Braille, or audio. You also have the right to file a complaint if you feel you’ve been discriminated against. Visit Medicare.gov/about- us/accessibility-nondiscrimination-notice, or call 1-800-MEDICARE (1-800-633-4227) for more information. TTY users can call 1-877-486-2048.

CMS Product No. 11636

Revised March 2019