SSA-1020 · SSA
Application for Extra Help with Medicare prescription drug plan costs. Can save up to $5,000/year on Part D premiums, deductibles, and copays.
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SSA.gov (recommended)
https://www.ssa.gov/i1020/Apply online for Extra Help with Medicare prescription drug costs.
Mail to Social Security Administration
Social Security Administration Wilkes-Barre Data Operations Center PO Box 1020 Wilkes-Barre, PA 18767-9899
In person at local SSA office
https://secure.ssa.gov/ICON/main.jspAbout 30 days. You will receive a notice of approval or denial.
If approved, you will pay reduced premiums, deductibles, and copays for Medicare Part D prescription drugs. Savings can be worth $5,000+ per year.
CMS-40B · CMS
Application for enrollment in Medicare Part B (medical insurance). Used during Initial Enrollment, General Enrollment, or Special Enrollment Periods.
CMS-L564 · CMS
Employer verification of group health plan coverage dates. Required alongside CMS-40B when using a Special Enrollment Period after employer coverage ends.
CMS-10797 · CMS
Application for Medicare Part A and Part B during a Special Enrollment Period for exceptional conditions such as natural disasters or employer misinformation.
CMS-10798 · CMS
Application for Part B immunosuppressive drug coverage for individuals who lose Part B but need ongoing immunosuppressive drug coverage after a kidney transplant.
Plan-specific (CMS model template) · CMS
Model enrollment form for Medicare Advantage or Part D prescription drug plans. Plans customize the CMS template but must include all required elements.
CMS model disenrollment form · CMS
Request to disenroll from a Medicare Advantage or Part D plan and return to Original Medicare. Available during applicable enrollment periods.
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