| MEDICARE PREMIUM BILL CENTERS FOR MEDICARE & MEDICAID
SERVICES (CMS)
BILLING DATE: (1)
MEDICAL PREMIUMS FOR
PERIOD ENDING: (2)
CURRENT AMOUNT DUE: (3)
PAYMENT DUE BY: (4)
• Return the bottom portion of this notice with your payment and use the enclosed
envelope to mail your payment.
• You must pay by check or money order. Include your Medicare number at the top of
your check or money order. Make the check or money order payable to: CMS MEDICARE
INSURANCE.
• If you have changed your address, be sure to write your new address in the space
provided below.
• If you have any questions concerning this Medicare Premium Bill, please write or
visit any Social Security Office.
PLEASE DETACH AT DOTTED LINE
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CMS-500A
Medicare Number: (5) Amount Due: $(6)
Name: (7)
Make Checks Payable To:
CMS MEDICARE INSURANCE
Send To:
Medicare Premium Collection Center
P.O. Box 790355
St. Louis, MO 63179-0355
( ) Check here if your address has changed.
Show new address below.
________________________________________
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PAYMENTS BY CHECK
When you provide a check as a payment, you authorize the Medicare Premium Collection
Center (MPCC) to use the information from your check to make a one-time electronic
funds transfer from your bank account. When the MPCC uses information from your check
to make an electronic funds transfer, they may withdraw funds from your bank account
as soon as the same day they receive your payment. You will not get your check back
from your bank. If the MPCC cannot process your payment electronically, they will
process it as a check transaction. Your bank statement will show the transaction as
"CMS Medicare" and this is your proof of payment.
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