Form Cms-500 - Medicare Premium Bill - Sample

ADVERTISEMENT

CMS–500 (2/16)
U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)
MEDICARE PREMIUM BILL
DATE:
YOUR MEDICARE NUMBER:
Ways to pay your bill:
Pay online at your bank’s website
•
Sign up for Medicare Easy Pay
•
Make a check or money order payable to
•
“CMS Medicare Insurance”
Use Visa, MasterCard, American Express, or Discover
•
Send payment with the coupon at the bottom to:
Medicare Premium Collection Center
P.O. Box 790355
St. Louis, MO 63179-0355
Part A
Part B
=
+
+
(Hospital
(Medical
Coverage
IRMAA
Total
Periods
Insurance)
Insurance)
Part D
Amount
Amount due for Part A and/or Part B
Past due amount for Part A and/or Part B
Amount due for IRMAA Part D
Past due amount for IRMAA Part D
Part A termination date:
Part B termination date:
Total amount due:
Part D termination date:
Payment in full due by:
Please send your full payment by
. Your payment is late if Medicare gets it after this date. If your bill
says “Delinquent” at the top, you must pay your bill in full by this date, or you could lose your coverage and you may
not be able to get your coverage back right away.
Partial payment may not stop you from losing your coverage.
Your bill shows new amounts and past amounts we didn’t get by your last bill’s due date.
We got your last payment of $
on
.
See other side for important information, including who to contact if you have questions.
Don’t send notes or letters with your payment. Cut at dotted line and return bottom with payment.
Check here if your name or address has changed or
is wrong, and complete the back of this paper.
Check here if the person has died.
Medicare Number:
$
Amount you are paying:
.
Write your Medicare number on your check or money order.
Visa/MasterCard/American Express/Discover Number:
Amount due:
Due in full by:
Don’t send cash. Make check/money order payable to:
CMS Medicare Insurance
Expiration Date: (MM/YYYY)
Send payment to:
MEDICARE PREMIUM COLLECTION CENTER
Credit/Debit Card Billing ZIP Code:
P.O. BOX 790355
ST. LOUIS, MO 63179-0355
Signature:
(over)

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Form Cms-20027 - Medicare Redetermination Request Form, Form Cms-20034 - Request For Medicare Hearing By An Administrative Law Judge Etc. Form Cms-20027 - Medicare Redetermination Request Form, Form Cms-20034 - Request For Medicare Hearing By An Administrative Law Judge Etc. Medical
Form Cms-855r - Medicare Enrollment Application - Reassignment Of Medicare Benefits Form Cms-855r - Medicare Enrollment Application - Reassignment Of Medicare Benefits Medical
Form Cms-838 Medicare Credit Balance Report Certification Page Form Cms-838 Medicare Credit Balance Report Certification Page Medical
Form Cms-460 - Medicare Participating Physician Or Supplier Agreement Form Cms-460 - Medicare Participating Physician Or Supplier Agreement Medical
Form Cms-46 - Medicare Participating Physician And Supplier Agreement Form Cms-46 - Medicare Participating Physician And Supplier Agreement Legal
Form Cms-8550 - Medicare Enrollment Application Form Cms-8550 - Medicare Enrollment Application Medical
Form Cms-20056 - Medicare Adminstration Observation Form Cms-20056 - Medicare Adminstration Observation Medical
Form Cms-20027 - Medicare Redetermination Request Form Cms-20027 - Medicare Redetermination Request Medical
Form Cms-855a - Medicare Enrollment Application - Institutional Providers Form Cms-855a - Medicare Enrollment Application - Institutional Providers Medical
Form Cms-855b - Medicare Enrollment Application - Clinics/group Practices And Certain Other Suppliers Form Cms-855b - Medicare Enrollment Application - Clinics/group Practices And Certain Other Suppliers Medical

Related Categories

Parent category: Medical
Download
Go
Page of 2