You will fill in your 11-character Medicare number from your Medicare card in the section that asks for the “Agency Account Identification Number.” When completing the form, write “Centers for Medicare & Medicaid Services” in the Agency Name section, and your name exactly as it appears on your Medicare card for the “Individual/Organization Name” section. If you are using a checking account for the automatic payments, you will also need to include a blank, voided check in the envelope when you submit your completed form. You will need a blank check from your bank account to complete your bank information. To complete the form, have your bank information and your red, white, and blue Medicare card handy. For people without access to the Internet or a printer, call 1-800-MEDICARE, and they will send you a form. This form is the application for the program, and includes instructions on how to complete. To sign up for Medicare Easy Pay, print and complete the Authorization Agreement for Preauthorized Payment form.
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