SF-5510 Authorization Agreement for Preauthorized Payments

SF-5510 Authorization Agreement for Preauthorized Payments

You’ll need the SF-5510 form if you’d like your Medicare premium deducted directly from your checking account.

What you’ll need:

• Basic information like current address and phone number
• Banking information
• A voided check if you’re using a checking account
• Your signature on the form

Other important information

• Processing can take up to 6-8 weeks.
• Payments will typically be deducted on the 20th of each month.
• Payments will read as “Automatic Clearing House (ACH)” on your bank statement.

Send completed forms and voided checks to the following address

Centers for Medicare & Medicaid Services Premium Collection Center
P.O. Box 979098
St. Louis, MO 63197-9000

Sponsored Content