CMS-2384 Third Party Premium Billing Request

CMS-2384 Third Party Premium Billing Request

You’ll need the CMS-2384 form if someone will be paying your Medicare premium bill on your behalf.

What you’ll need:

• Basic information
• Medicare number
• Your signature
• Signature of the third party payer

Other important information:

• The third party payer can be a relative, spouse, or someone else financially responsible for your monthly Medicare premium.
• If Medicare approves your request, your monthly premium bill will be mailed directly to the third party payer.

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