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Get Sf 5510 Pdf 2017-2024

By completing and returning the Authorization Agreement for Preauthorized Payments form SF-5510 you re authorizing the deduct your monthly Medicare premium 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. 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. Mail the completed form to the address above. You can get a new form at www. medicare. gov or by calling 1-800-MEDICARE. AUTHORIZATION AGREEMENT FOR PREAUTHORIZED PAYMENTS OMB No. 1510-0059 Expires 01/31/2014 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. 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. 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 a few tips to help you When the form asks for Individual/Organization Name Your Agency Account Identification Number Type of Payment Nine-Digit Routing Number Account Title Account Number Do this Enter your name the way it looks on your Medicare card. Enter your Medicare number from your Medicare card. Enter Medicare Premiums this field is prefilled on the form. Enter the number from the bottom left corner of your check. Enter the name of the account holder or the individual who has power of attorney. Enter the checking or savings account number don t use spaces or symbols. If you re using a checking account to pay your premiums attach a voided check for your checking account. Where do I send the completed form 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. CMS Product No* 11636 January 2013 Two things will happen each month after your request is processed 1. You ll get a Notice of Medicare Premium Payment Due stating This is not a bill to let you know that the premium will be deducted from your bank account.

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