Form Cms-40b - Application For Enrollment In Medicare - Part B (Medical Insurance)
Download a blank fillable Form Cms-40b - Application For Enrollment In Medicare - Part B (Medical Insurance) in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Cms-40b - Application For Enrollment In Medicare - Part B (Medical Insurance) with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4DEPARTMENT OF HEALTH AND HUMAN SERVICES
Form Approved
CENTERS FOR MEDICARE & MEDICAID SERVICES
OMB No. 0938-1230
APPLICATION FOR ENROLLMENT IN MEDICARE PART B (MEDICAL INSURANCE)
WHO CAN USE THIS APPLICATION?
WHAT HAPPENS NEXT?
People with Medicare who have Part A but not Part B
Send your completed and signed application to your local
Social Security office. If you sign up in a SEP, include the
NOTE: If you do not have Part A, do not complete this form.
CMS-L564 with your Part B application. If you have questions,
Contact Social Security if you want to apply for Medicare for
call Social Security at 1-800-772-1213. TTY users should call
the first time.
1-800-325-0778.
WHEN DO YOU USE THIS APPLICATION?
HOW DO YOU GET HELP WITH THIS
Use this form:
APPLICATION?
• If you’re in your Initial Enrollment Period (IEP) and live in
• Phone: Call Social Security at 1-800-772-1213. TTY users
Puerto Rico. You must sign up for Part B using this form.
should call 1-800-325-0778.
• If you’re in your IEP and refused Part B or did not sign up
• En español: Llame a SSA gratis al 1-800-772-1213 y oprima
when you applied for Medicare, but now want Part B.
el 2 si desea el servicio en español y espere a que le
• If you want to sign up for Part B during the General
atienda un agente.
Enrollment Period (GEP) from January 1 – March 31
• In person: Your local Social Security office. For an office
each year.
near you check
• If you refused Part B during your IEP because you had
group health plan (GHP) coverage through your or your
spouse’s current employment. You may sign up during
REMINDERS
your 8-month Special Enrollment Period (SEP).
• If you sign up for Part B, you must pay premiums for
• If you have Medicare due to disability and refused Part
every month you have the coverage.
B during your IEP because you had group health plan
• If you sign up after your IEP, you may have to pay a late
coverage through your, your spouse or family member’s
enrollment penalty (LEP) of 10% for each full 12-month
current employment.
period you don’t have Part B but were eligible to sign up.
• You may sign up during your 8-month SEP.
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?
You will need:
• Your Social Security Claim Number
• Your current address and phone number
• Form CMS-L564 ”Request for Employment Information”
completed by your employer if you’re signing up in a SEP.
CMS-40B (04/17)
1
ADVERTISEMENT
0 votes
Related Articles
Related forms
Formulario Cms-40b - Solicitud De Inscripcion Para Medicare Parte B (seguro Medico) (spanish Version)
Medical
Form Cms-1856 - Request For Certification In The Medicare And/or Medicaid Program To Provide Outpatient Physical Therapy And/or Speech Pathology Services
Medical
Related Categories
Parent category: Medical