Medicare Form Summary
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.