Medicare Forms and Information


Authorization to Disclose Protected Health Information (PHI) Form
Automated Premium Payment (ACH) Form
CMS Appointment of Representative
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 - HMO
Prescription Drug Claim Form - PPO

This information is available for free in other languages. Please call our Customer Service number at Customer Service at: 1-877-774-8592 TTY/TDD: 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 Customer Service at: 1-877-774-8592 TTY/TDD: 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 Medicare benefits and services, including general information about Medicare Advantage Prescription Drug coverage.


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.


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