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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
You must sign up for Part B using this form. NOTE: Your IEP lasts for 7 months. It begins 3 months before your 65th birthday (or 25th month of disability) and ends 3 months after you reach 65 (or 3 months after the 25th month of disability). WHAT INFORMATION DO YOU NEED TO COMPLETE THIS APPLICATION? WHAT HAPPENS NEXT?
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).
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.
Get the forms you need to sign up for Part B including CMS-40B, CMS-L564, CMS-10797, and CMS-10798.
Form Approved OMB No. 0938-1230 Expires: 04/24 . SPECIAL MESSAGE FOR INDIVIDUAL APPLYING FOR PART B . 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
Medicaid Services (CMS) to determine if you are entitled to Supplementary Medical Insurance (Part B). Completing this form is voluntary, but you will not be enrolled in Part B if you do not provide all of the required information.
You can also submit the completed and signed forms CMS-40B and CMS-L564 (or written notifications) by mail or by contacting your local Social Security office.
• Downloading Form CMS-40B (Application for Enrollment in Medicare Part B) at Medicare.gov/basics/forms-publications-mailings/forms/enrollment. Complete the application and sign it. Return the completed application to your local Social Security office. • Calling Social Security at 1-800-772-1213. TTY users can call 1-800-325-0778.
Form CMS-L564 ”Request for Employment Information” completed by your employer if you’re signing up in a SEP. WHAT HAPPENS NEXT? Send your completed and signed application to your local Social Security office. If you sign up in a SEP, include the CMS-L564 with your Part B application. If you have questions, call Social Security at 1-800-772-1213.