Get Md Cms-5510 2017-2025

The MD CMS-5510 form, also known as the Authorization Agreement for Preauthorized Payments, is essential for authorizing the Centers for Medicare & Medicaid Services to deduct your monthly Medicare premiums directly from your bank account. This guide provides clear, step-by-step instructions to help you complete the form online with ease.

Follow the steps to complete the MD CMS-5510 form online.

1. Click ‘Get Form’ button to obtain the MD CMS-5510 form and open it in your preferred digital form editor.
2. Begin filling out the form by providing your personal details. The 'Agency Name' should read 'Centers for Medicare & Medicaid Services'.
3. In the 'Individual/Organization Name' field, enter your name exactly as it appears on your Medicare card.
4. Locate your 'Agency Account Identification Number', which is your 11-character Medicare Number found on your Medicare card.
5. Specify the 'Type of Payment' as 'Medicare Premiums' in the appropriate section.
6. Input your 'Nine-Digit Routing Number', which you can find at the bottom left corner of your bank check.
7. Fill in the 'Account Title' with the name of the account holder of your checking or savings account.
8. Enter your 'Account Number', ensuring not to include any spaces or symbols.
9. If a representative at your bank helped you with the form, fill in the 'Signature and Title of Representative' section. Otherwise, you can leave this blank.
10. If you are submitting the form with a checking account, make sure to attach a blank, voided check to validate the Routing and Account numbers provided.
11. Once all fields are filled out accurately, review the form for any errors. Save your changes, then download or print the completed document as needed.
12. Send the completed form to: Centers for Medicare & Medicaid Services, Medicare Premium Collection Center, P.O. Box 979098, St. Louis, MO 63197-9000.

Start completing your MD CMS-5510 form online today.