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You can apply online or you can mail your completed CMS 40B, Application for Enrollment in Medicare - Part B (Medical Insurance) to your local Social Security office. You’ll also need to send CMS L564 - Request for Employment Information, and a required proof of employment, Group Health Plan (GHP), or Large Group Health Plan (LGHP) coverage ...
This form is your application for Medicare Part B (Medical Insurance). You can use this form to sign up for Part B: During your Initial Enrollment Period (IEP) when you’re first eligible for Medicare. During the General Enrollment Period (GEP) from January 1 through March 31 of each year.
WHEN DO YOU USE THIS APPLICATION? Use this form: • If you’re in your IEP and refused Part B or did not sign up when you applied for Medicare, but now want Part B. • If you want to sign up for Part B during the General Enrollment Period (GEP) from January 1 – March 31 each year. • If you’re eligible for a Special Enrollment Period (SEP).
Get the forms you need to sign up for Part B including CMS-40B, CMS-L564, CMS-10797, and CMS-10798.
Fill out the Application for Enrollment in Medicare Part B (CMS-40B) (PDF). If you are applying during the Special Enrollment Period, also fill out the Request for Employment Information (CMS-L564) (PDF) .
time estimate(s) or suggestions for improving this form, please write to: CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850. CMS-40B (04/18) 2 Form Approved OMB No. 0938-1230 Expires: 02/20
Application for Enrollment in Medicare Part B (Medical Insurance) DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. Form Approved. OMB No. 0938-1230 Expires: 01/25.