Issued by SSA. This site is not the issuer. Checked against the issuer on 2026-11-03. Issuer's page · Instructions: on the form, pages 5–8
People who receive a notice that their Medicare Part B or prescription drug coverage premiums include an income-related monthly adjustment amount (IRMAA) use this form if they had a major life-changing event that reduced their income. You submit it to the Social Security Administration or call to schedule an office interview. Have ready your Social Security number, the date of your life-changing event, and figures for your adjusted gross income and tax-exempt interest income from your tax return.