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STANDARD FORM 5510 PDF FILLABLE PLUS

If your bank rejects or returns your premiums deduction, we’ll send you a letter with instructions on other ways to pay your premiums. We’ll only try to deduct your premiums once each month. Until then, you must pay your Medicare premiums another way. Once the amount you owe is within the limits, your automatic deductions can begin. If you owe more than these limits, we won’t be able to deduct your premiums.

STANDARD FORM 5510 PDF FILLABLE PLUS

After the initial deduction, 1 month’s premiums plus $10 is the maximum deduction each month. Your initial ACH deduction can be up to 3 months’ premiums. It will appear on your bank statement as a “CMS Medicare Premium” Automated Clearing House (ACH) transaction. We’ll deduct your premiums from your bank account, usually on the 20th of each month. (Visit for more information on ways to pay your premiums.) How do automatic bank deductions work? 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. If we can’t process your form, we’ll return the form to you with a letter explaining why. Louis, MO 63197-9000 What happens once I return this form?

We’ll use it to validate the Routing and Account numbers you provided on the form. If you’re using a checking account to pay your premiums, attach a blank, voided check.

The “Signature and Title of Representative” should be completed only if someone at your bank helps you complete the form.

The “Account Number” is the checking or savings account number (don’t use spaces or symbols).

The “Account Title” is the name of the checking or savings account holder.

Your “Nine-Digit Routing Number” is the number from the bottom left corner of your check.

The “Type of Payment” should be “Medicare Premiums”.

Your “Agency Account Identification Number” is your 11-character Medicare Number from your Medicare card.

The “Individual/Organization Name” is your name the way it looks on your Medicare card.

The “Agency Name” should be “Centers for Medicare & Medicaid Services”.

Here are some tips to help you complete the form: Have your red, white, and blue Medicare card and a blank check from your bank account with you when you fill out the form. The form asks for basic information about you and your bank (also called a financial institution). What information do I need to put on the form? This notice tells you what happens once you complete and return the form. 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. Thank you for your interest in Medicare Easy Pay.