Welcome

Let's prepare your IRMAA appeal.

We'll walk through everything Social Security needs on Form SSA-44 and Form SSA-795 — in plain English, one question at a time. Most clients finish in about 15 minutes, and your progress saves automatically.

What you'll need handy:

Your Medicare card or claim number
The IRMAA notice you received from Social Security
An estimate of your reduced income (or your most recent tax return)
Documentation of your life-changing event

Progress saved automatically

Who is appealing?

If you and your spouse both have Medicare and both received an IRMAA notice, we'll prepare appeal forms for both of you. Each spouse needs their own SSA-44 and SSA-795.

Just me

I'm the only one on Medicare with an IRMAA surcharge

Me and my spouse

We both have Medicare and both received IRMAA notices

Tell us about yourself.

This is the person who received the IRMAA notice. Your name must match your Social Security card exactly.

First name *

Required.

Last name *

Required.

Middle initial optional

Date of birth *

Required.

Social Security Number *

Please enter a valid 9-digit SSN.

Medicare number optional

Phone number *

Required.

Email address *

Required.

Mailing address *

Required.

City *

Required.

State *

Required.

ZIP *

Required.

Now tell us about your spouse.

Your spouse will receive their own SSA-44 and SSA-795 to sign separately. Their information must match their Social Security card exactly.

Spouse first name *

Required.

Spouse last name *

Required.

Middle initial optional

Date of birth *

Required.

Spouse Social Security Number *

Please enter a valid 9-digit SSN.

Spouse Medicare number optional

Spouse phone optional, if different

Spouse email optional, if different

Same address as you? If your spouse lives at the same address you entered, you can leave this section blank. We'll use yours.

Spouse mailing address if different

City

State

ZIP

What premium year is on your notice?

The IRMAA notice from Social Security tells you which calendar year your higher premium applies to.

2026 2025

What tax year did SSA use?

Listed on your IRMAA notice. SSA usually uses your return from two years before the premium year.

2024 — 2 years before 2026 2023 — 3 years before 2026, or 2 before 2025 2022 — 3 years before 2025

What life-changing event applies to you?

SSA only adjusts your premium for these eight specific events. If more than one applies, choose the most significant.

Work stoppage

You or your spouse stopped working entirely (retirement, layoff, etc.)

Work reduction

You or your spouse cut back hours or moved to lower-paying work

Marriage

You got married, changing your filing status

Divorce or annulment

Your marriage legally ended

Death of your spouse

Your spouse passed away

Loss of pension income

A pension was terminated, reduced, or reorganized

Loss of income-producing property

Disaster, theft, or fraud — not a voluntary sale

Employer settlement payment

Settlement due to bankruptcy or reorganization

Tell us what happened.

The date and your description of the event in your own words. This becomes the heart of your statement on Form SSA-795 — our team polishes it into formal language.

When did this happen? *

Required.

In your own words, describe what happened *

Include dollar amounts, dates, and employer or source names where possible. Aim for 4–8 sentences.

Please describe what happened.

What is your tax filing status?

For the year your reduced income applies to — the year we'll ask SSA to use.

Single — threshold: $109,000 Married, Filing Jointly — threshold: $218,000 Married, Filing Separately — threshold: $109,000 Head of Household — threshold: $109,000 Qualifying Widow(er) — threshold: $109,000

Your income after the event.

Tell us what your income looks like in the more recent tax year — the one we'll ask SSA to use instead of the older return on your notice.

For reference: 2026 IRMAA thresholds

Single	Joint	Premium impact
≤ $109,000	≤ $218,000	No IRMAA
$109K–$137K	$218K–$274K	+$81/mo
$137K–$171K	$274K–$342K	+$203/mo
$171K–$205K	$342K–$410K	+$325/mo
$205K–$500K	$410K–$750K	+$446/mo
> $500K	> $750K	+$487/mo

Tax year for reduced income *

Required.

Are these actual or estimated figures? *

Actual

I have my filed 1040 in hand

Estimate

My best projection

Adjusted Gross Income (AGI) *

Line 11 of your 1040.

Required.

Tax-exempt interest *

Line 2a of your 1040. Enter $0 if you don't have any.

Required.

MAGI = AGI + Tax-exempt interest. SSA adds these together to determine your IRMAA. We'll calculate this for you on the review screen.

Will next year be even lower?

If your income drops further next year, telling SSA now saves you from filing a second appeal later. Skip if next year will look the same or higher.

Yes, lower

Income drops further

No, same or higher

Skip this section

What documentation do you have?

SSA needs proof of your event and your reduced income. Don't worry if you're missing something — we'll let you know what's still needed.

For your event, SSA accepts:

Check everything you currently have Employer letter or pay stubsStatement of termination, retirement, or reduced hours Marriage certificateOriginal or certified copy Divorce or annulment decreeCertified copy Death certificateCertified copy Pension administrator letterExplaining termination or reduction of benefits Insurance adjuster or government letterDocumenting property loss (or theft/fraud conviction) Employer settlement letterBankruptcy or reorganization terms Filed tax return (1040)Signed copy or IRS transcript for the reduced-income year None yet — I need help gathering documentsWe'll provide a personalized checklist

Anything else we should know? optional

· Review

Make sure we've got it right.

Review every section below. Tap "Edit" to make changes. Accuracy here directly determines whether SSA approves your appeal.

Disclosures

Before you sign.

Please read carefully. By signing, you confirm the information you provided is accurate and you understand the limits of our service.

1. Accuracy of information

You ("Client") confirm that all information provided in this intake form is true, complete, and accurate to the best of your knowledge. goodbyeirmaa.com prepares Form SSA-44 and Form SSA-795 solely on the basis of the information you submit. We do not verify, audit, or independently confirm the accuracy of any income figures, dates, employment details, life-changing events, or supporting documentation you describe.

2. No legal, tax, or financial advice

goodbyeirmaa.com is a document-preparation service. We are not a law firm, accounting firm, or registered tax advisor, and our services do not constitute legal, tax, financial, or actuarial advice. Nothing on this site or in any communication with us creates an attorney-client, fiduciary, or advisory relationship.

3. No guarantee of outcome

The decision to approve or deny an IRMAA appeal rests entirely with the Social Security Administration. goodbyeirmaa.com does not and cannot guarantee any specific outcome, including approval of your appeal, reduction of premiums, or refund of previously paid amounts.

4. Limitation of liability

Client acknowledges and agrees that:

goodbyeirmaa.com is not liable for any false, inaccurate, incomplete, or misleading information provided by Client, regardless of whether such inaccuracy was intentional, negligent, or accidental.
goodbyeirmaa.com is not responsible for the repayment of any funds, premiums, surcharges, penalties, interest, or amounts owed to the Social Security Administration, the Centers for Medicare & Medicaid Services, the Internal Revenue Service, or any other government agency, whether arising from a denied appeal, an overturned approval, an audit, or otherwise.
goodbyeirmaa.com's total aggregate liability for any claim arising from the services provided shall not exceed the fees actually paid by Client for those services.

5. Submission to SSA

goodbyeirmaa.com prepares your appeal documents for your review and signature. Final submission of forms to SSA is the Client's responsibility, including ensuring that supporting documentation is included and that the package is delivered to SSA via mail, fax, or in-person appointment within applicable deadlines.

6. Privacy

Information you provide is transmitted securely and used solely to prepare your appeal. We do not sell your personal information.

7. Penalty of perjury

The signed SSA forms include a declaration under penalty of perjury. By providing this information and signing your forms, you affirm that all statements are true. Knowingly providing false information to SSA is a federal crime.

I confirm everything I provided is accurate.I understand my appeal is based on the information I supplied. I accept the limitations of liability.goodbyeirmaa.com is not liable for false information I provided or any repayment of funds owed to SSA, CMS, IRS, or any other agency. I understand approval is not guaranteed.SSA makes the final decision on my appeal.

Sign & submit

Sign your intake.

Your signature here authorizes goodbyeirmaa.com to prepare your SSA-44 and SSA-795 forms. You'll separately sign the actual SSA forms before they're submitted to Social Security.Both you and your spouse need to sign. These signatures authorize goodbyeirmaa.com to prepare each of your SSA-44 and SSA-795 forms. You'll both separately sign the actual SSA forms before submission.

Your signature

Type your full legal name *

Match your Social Security card.

Required.

Draw your signature optional but recommended

Use your finger on mobile or your mouse on desktop.

Date *

Required.

Phone *

Required.

Spouse's signature

Spouse's full legal name *

Must match their Social Security card.

Required.

Draw spouse's signature optional but recommended

Date *

Required.

What happens next: Within 1 business day, we prepare your SSA-44 and SSA-795 forms based on this intake. You'll receive a secure link to review the completed forms, sign the actual SSA documents, and a step-by-step guide for submitting them to Social Security.

Your Intake is Complete

We've received everything we need to start preparing your appeal. A confirmation email is on its way to . Expect your completed SSA-44 and SSA-795 forms within 1 business day.

Your reference number:
Save this for any questions or status updates.

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