Fillable Form 5510 AUTHORIZATION AGREEMENT FOR PREAUTHORIZED PAYMENTS 2017

Fill Online, Printable, Fillable, Blank Form 5510 AUTHORIZATION AGREEMENT FOR PREAUTHORIZED PAYMENTS 2017 Form

Use Fill to complete blank online MEDICARE & MEDICAID pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Form 5510 AUTHORIZATION AGREEMENT FOR PREAUTHORIZED PAYMENTS 2017

On average this form takes 8 minutes to complete

The Form 5510 AUTHORIZATION AGREEMENT FOR PREAUTHORIZED PAYMENTS 2017 form is 3 pages long and contains:

  • 2 signatures
  • 0 check-boxes
  • 25 other fields

Country of origin: US
File type: PDF

BROWSE MEDICARE & MEDICAID FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
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
OMB No.: 1530-0015
AUTHORIZATION AGREEMENT FOR PREAUTHORIZED PAYMENTS
(AGENCY NAME)
Paperwork Reduction Act/Privacy Act Statement
The information requested on this form is required under various provisions of title 15 USC Chapter 41, 12 CFR 205, and 31
CFR 202 and 206, for the purpose of authorizing the Department of Treasury to designate financial institutions to electronically
collect payments from your account. The information will be used to match the records of the government agency with those of
the financial institution to direct your payments to the point you authorize. No electronic collection from your account may be
transacted unless a signed authorization form is received. Furnishing this information is voluntary, however, failure to furnish this
information may delay or prevent the electronic collection of a payment through the Automated Clearing House. You are not
required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number
for this collection of information is 1530-0015. We estimate that it will take approximately 15 minutes to complete this form.
CHECK ONE:
CHANGE START STOP
INDIVIDUAL/COMPANY INFORMATION
INDIVIDUAL/ORGANIZATION NAME (PLEASE PRINT)
STREET ADDRESS
CITY/STATE: ZIP CODE:
AREA CODE: TELEPHONE NUMBER:
YOUR AGENCY ACCOUNT IDENTIFICATION NUMBER:
TYPE OF PAYMENT:
I hereby authorize the initiation of a deduction from my account and the financial institution named below to debit such account. I
understand I will be notified if the debit amount needs to be adjusted, either to be increased or decreased. I also understand that I have
the right to stop automatic payment by notifying my financial institution in writing three days prior to the time my account is charged.
SIGNATURE: __________________________________________________________________________ DATE: _____________________________________
FINANCIAL INSTITUTION INFORMATION
FINANCIAL INSTITUTION NAME:
STREET ADDRESS
CITY/STATE: ZIP CODE:
NINE-DIGIT ROUTING TRANSIT NUMBER:
►
ACCOUNT TITLE
ACCOUNT NUMBER
CHECKING
SAVINGS
SIGNATURE AND TITLE OF REPRESENTATIVE AREA CODE/TELEPHONE NUMBER DATE
DEPARTMENT OF THE TREASURY PREVIOUS EDITION NOT USABLE
STANDARD FORM 5510 (Rev. 03/2017)
AUTHORIZED FOR LOCAL REPRODUCTION
31 CFR 202 and 206; I TFM 6-8000
click to sign
signature
click to edit
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Form 5510 AUTHORIZATION AGREEMENT FOR PREAUTHORIZED PAYMENTS 2017

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 16 February 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document