HCA Medicare Required Documentation Samples

Listed below are samples of documentation you need to send us for proof of your Medicare plan(s). You can upload them by filling out the Medicare Healthcare Cost Assistance Benefits Request Form or by logging in to MyCarewell503.org* (currently available in English).

Medicare Premium Bill Samples

CMS Medicare Premium Bill Sample

SSA Cost-of-Living-Adjustment (COLA) Letter Sample

SSA Benefit Verification Letter Sample

Medicare Supplement Plan G Sample

Medicare SSA Part B Sample

Medicare Advantage Premium Bill Sample

For more information

Visit these pages to learn more about your benefits and how to use them if you are eligible:
*How to update your Medicare coverage on MyCarewell503
Forms Webpage
Medicare Healthcare Cost Assistance Webpage
FAQs Webpage
MyCarewell503

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