Appeals & Form
Medicare & Social Security Help Hub: The forms you need. The clarity you’ve been missing.
Medicare Forms
(Non-Appeals)
CMS-40B
Application for Enrollment in Medicare Part B
Use this form if you're already enrolled in Part A and need to enroll in Part B.
CMS-L564
Request for Employment Information
Required when applying for Part B with a Special Enrollment Period due to having employer coverage.
CMS-10106
Medicare Authorization to Disclose Personal Health Information
Allows Medicare to release your health info to someone you choose.
CMS-1763
Request for Termination of Premium Hospital and/or Supplementary Medical Insurance
Used to voluntarily cancel Medicare Part B.
CMS-R-2971
Notice of Medicare Non-Coverage (NOMNC)
Given when services are ending so you can appeal if needed. This is not something you typically file but good to understand if you receive it.
CMS-2728-U3
ESRD Medical Evidence Report
Used to document end-stage renal disease for Medicare eligibility.
SF 5510
Authorization Agreement for Preauthorized Payments
Want your Medicare premiums taken out automatically each month? This form allows you to set up automatic bank withdrawals for Medicare premiums if you're not already having them deducted from your Social Security check.
Helpful Tip:
This is a great option if you’ve delayed collecting Social Security or are paying Medicare directly.
Social Security Forms
(Non-Appeals)
SSA-1
Application for Retirement Insurance Benefits
Used to apply for Social Security retirement benefits.
SSA-44
Medicare Income-Related Monthly Adjustment Amount – Life-Changing Event
To request a reduction in IRMAA if your income decreased due to certain events (like retirement).
SSA-89
Authorization for SSA to Release Social Security Number Verification
Used by third parties needing identity confirmation.
SSA-3288
Consent for Release of Information
Authorizes SSA to release your records to someone else.
SSA-7050
Request for Social Security Earnings Information
Provides a full earnings record (useful for checking benefit accuracy or for legal/financial needs).
SSA-1696
Appointment of Representative
If someone (like a professional advocate or family member) is helping with your application or communication.
SSA-521
Request for Withdrawal of Application
Allows someone to withdraw their Social Security claim within 12 months and reapply later. Helpful in “buyer’s remorse” situations.
SSA-632
Request for Waiver of Overpayment Recovery
If someone was overpaid by SSA and wants the repayment forgiven.
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Medicare Appeals Forms
CMS-20027
Medicare Redetermination Request Form
Used to request a redetermination (first-level appeal) of a Medicare Part A or Part B claim.
CMS-20031
Reconsideration Request Form
For a second-level appeal if you disagree with the redetermination decision.
CMS-1696
Appointment of Representative
Used if someone is helping you with your appeal (such as an agent or family member).
Download CMS-1696
Request for an Appeal of a Part D Decision
(Coverage Determination or Redetermination)
Often provided by the plan provider, but a generic version may be used.
OMHA-100
Request for Administrative Law Judge Hearing
Used for Level 3 Medicare appeals after reconsideration denial.
Social Security Appeals Forms
SSA-561-U2
Request for Reconsideration
First step in appealing most Social Security decisions (such as benefit denials or penalties).
SSA-3441
Disability Report – Appeal
Required if you're appealing a disability decision.
SSA-827
Authorization to Disclose Information to the Social Security Administration
Allows SSA to obtain your medical records for a disability appeal.
SSA-89
Authorization for SSA to Release Social Security Number Verification
Sometimes needed when additional identity verification is required.
HA-501
Request for Hearing by Administrative Law Judge
Used when a reconsideration is denied, and you want a hearing.
How to Submit These Forms
Medicare Forms:
Usually faxed or mailed to your local Social Security office. Some can be submitted through your SSA.gov account.
Appeals Forms:
Follow the instructions on the form or contact your insurance plan/SSA office for help. Keep a copy for your records.
Frequently Asked Questions
Do I need to fill out all of these forms?
No—only the ones that apply to your specific situation. Each form includes a brief description to help guide you. Not sure which one fits? Reach out and our team can help.
How do I submit these forms?
Most Medicare and Social Security forms can be faxed, mailed, or submitted through your SSA.gov account. Check each form for exact instructions. If you're a client, we can help you upload or fax them securely.
What if I’m not sure which form to use?
You’re not alone. That’s exactly why we built this page—to bring clarity. If you’re stuck, contact us so we can walk through it together.
Is there a deadline for filing appeals?
Yes. Medicare and Social Security appeals usually have time limits (e.g., 60 days from receiving a denial). Don’t wait—reach out if you’re not sure how to start.
Can I authorize someone to help me with my case?
Yes! Use the SSA-1696 (Social Security) or CMS-10106/CMS-1696 (Medicare) forms to appoint a representative. We can even help you fill those out if needed.
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