Required Forms


Required Forms

New to Medicare? Leaving employer coverage? Wondering what to do about your HSA? Re-enrolling in or terminating Medicare coverage? Wondering how to set up a account? We have you covered.



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Turning 65?

Below are the applications you’ll need to enroll in Medicare for the first time, apply for subsidies, and/or maintain coverage if anything changes.

Or call our office for assistance: 1 (888) 467-4811.

Apply for Retirement, Spouse, or Medicare Benefits Apply Now

Get Help With Medicare Prescription Drug Costs Submit Online

Change of Address or Telephone Number Change Here

Leaving Group Health?

If you have Medicare Part A only, you will need the 2 following forms to activate your Medicare Part B. Once you have both forms completed, you can send them to your local Social Security office or email one of our Senior Account Managers directly and they will upload them straight to Social Security for you. If you have an HSA Group Health Plan, a third form will be required so you will not receive penalty (see below regarding HSA form).

Medicare Part B Activation Request CMS - 40B

Employer Verification CMS - L564

Leaving Group HSA Plans – over 65

This is a special form that needs to be completed and sent or uploaded to Social Security with your Medicare Part B activation forms so your Part A isn’t backdated.

Request for Termination of Hospital Backdating

CMS - 1763

Returning to Group Health – over 65

If you have any questions about any of the above forms, enrollment in general, or are having trouble finding any requested forms not listed: please don’t hesitate to reach out to one of our nationally-recognized advisors: We will always make it work for you.

Request for Termination of Hospital Backdating

CMS - 1763

Create a Account

  1. Go to
  2. Click on at the top right hand corner
  3. Go to, “No account? Create an account now". You will need your Medicare number and Part A coverage start date.
  4. It will ask you to create a Username and Password and secret question.
  5. Submit.