To get the Medicare form you need, find the situation that applies to you. Get forms in alternate formats.
Fill out Authorization to Disclose Personal Health Information. Get this form in Spanish.
Fill out the Patient Request for Medical Payment form (CMS-1490S).You'll find the address for form submission in the instructions. Follow the instructions on the second page to submit the form to your carrier. Get this form in Spanish.
If you don't know the address for your carrier, you can:
Fill out the Request for Hearing by an Administrative Law Judge form [PDF, 96.6 KB] (CMS-20034A/B).