Form Cms-4040 - Request For Enrollment In Supplementary Medical Insurance

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
TOE 810
Do Not Write In This Space
CENTERS FOR MEDICARE & MEDICAID SERVICES
Form approved
OMB. No. 0938-0245
REQUEST FOR ENROLLMENT
IN SUPPLEMENTARY MEDICAL INSURANCE
According to the Paperwork Reduction of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB
control number. The valid OMB control number for this information collection of 0938-0245. The time required to complete this information
collection is estimated to average 15 minutes per response, including the time to review instructions, search existing data resources, gather the data
needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or
suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, N2-14-26, Baltimore, Maryland 21244-1850.
PRIVACY ACT NOTICE: The Social Security Administration (SSA) is authorized to collect the information on this form under sections 1836,
1840, and 1872 of the Social Security Act, as amended (42 U.S.C. 1395o, 1395s, and 1395ii). The information on this form is needed to enable
Social Security and the Centers for Medicare & Medicaid Services (CMS) to determine if you are entitled to supplementary medical insurance
benefits. While you do not have to furnish the information requested on this form to Social Security, no medical insurance can be provided until an
application has been received by the Social Security office. Failure to provide all or part of the information requested could prevent an accurate and
timely decision on your application for enrollment or could be cause for denial of insurance entitlement. Although the information you furnish on this
form is almost never used for any other purpose than stated above, there is a possibility that for the administration of the Social Security or CMS
programs or for the administration of programs requiring coordination with SSA or CMS, information may be disclosed to another person or to
another governmental agency as follows: 1) to enable a third party or an agency to assist Social Security or CMS in establishing rights to Social
Security benefits and/or hospital or medical insurance coverage; 2) to comply with Federal laws requiring the release of information from Social
Security and CMS records (e.g., to the General Accounting Office and the Veterans Administration); and 3) to facilitate statistical research and audit
activities necessary to assure the integrity and improvement of the Social Security and CMS programs (e.g., to the Bureau of the Census and private
concerns under contract to Social Security and CMS). In addition, you should be aware that the information you provide may be verified by way of
computer matches in accordance with the Computer Matching and Privacy Protection Act of 1988 (P.L. 100-503).
I wish to enroll in Medicare’s supplementary medical insurance benefits plan described under title XVIII of the Social Security Act, as
presently amended. I understand that a premium payment will be due for each month of coverage under this plan. (See reverse side for
further explanation.)
(FIRST NAME, MIDDLE INITIAL, LAST NAME)
1.
a. PRINT your name
b. Enter your name at birth if different from 1(a)
c. Enter your sex (check one)
Male
Female
d. Enter your Social Security Number
___ ___ ___ / ___ ___ / ___ ___ ___ ___
2.
a. Enter your date of birth (Month, day, year)
b. Enter name of State or foreign country where you were born
If you have not submitted proof of your age complete (c) and (d).
c. Was a public record of your birth made before you were age 5?
Yes
No
Unknown
d. Was a religious record of your birth made before you were age 5?
Yes
No
Unknown
3.
Have you ever before enrolled for supplementary medical insurance
under Medicare?
Yes
No
4.
a. Do you or your spouse receive a monthly annuity under the Federal
Civil Service Retirement Act or other law administered by the
Office of Personnel Management?
Yes
No
(If “Yes,” answer (b). If “No,” go on to item 5.)
YOUR NO.
b. Enter the Civil Service annuity number here.
(Include the prefix, i.e., “CSA” for annuitant, “CSF”
for survivor.)
SPOUSE’S NO.
If you entered your spouse’s number, is he (she) enrolled for
Yes
No
supplementary medical insurance?
Form CMS-4040 (8/91)
Page 1

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