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Fillable Printable Application for Enrollment in Medicare Part B (Medical Insurance)

Fillable Printable Application for Enrollment in Medicare Part B (Medical Insurance)

Application for Enrollment in Medicare Part B (Medical Insurance)

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
APPLICATION FOR ENROLLMENT IN MEDICARE PART B (MEDICAL INSURANCE)
WHO CAN USE THIS APPLICATION?
People with Medicare who have Part A but not Part B
NOTE: If you do not have Part A, do not complete this form.
Contact Social Security if you want to apply for Medicare for
the first time.
WHEN DO YOU USE THIS APPLICATION?
Use this form:
If you’re in your Initial Enrollment Period (IEP) and live in
Puerto Rico. You must sign up for Part B using 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 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
your 8-month Special Enrollment Period (SEP).
If you have Medicare due to disability and refused Part
B during your IEP because you had group health plan
coverage through your, your spouse or family member’s
current employment.
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.
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. TTY users should call
1-800-325-0778.
HOW DO YOU GET HELP WITH THIS
APPLICATION?
Phone: Call Social Security at 1-800-772-1213. TTY users
should call 1-800-325-0778.
En español: Llame a SSA gratis al 1-800-772-1213 y oprima
el 2 si desea el servicio en español y espere a que le
atienda un agente.
In person: Your local Social Security office. For an office
near you check www.ssa.gov.
REMINDERS
If you sign up for Part B, you must pay premiums for
every month you have the coverage.
If you sign up after your IEP, you may have to pay a late
enrollment penalty (LEP) of 10% for each full 12-month
period you don’t have Part B but were eligible to sign up.
CMS-40B (04/17) 1
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
Form Approved
OMB No. 0938-1230
APPLICATION FOR ENROLLMENT IN MEDICARE PART B (MEDICAL INSURANCE)
1. Your Social Security Claim Number
Beneficiary Identification Code (BIC)
2. Do you wish to sign up for Medicare Part B (Medical Insurance)?
YES
3. Your Name (Last Name, First Name, Middle Name)
4. Mailing Address (Number and Street, P.O. Box, or Route)
5. CityState
Zip Code
6. Phone Number (including area code)
(
)
7. Written Signature (DO NOT PRINT)
SIGN HERE
8. Date Signed
/
/
IF THIS APPLICATION HAS BEEN SIGNED BY MARK (X), A WITNESS WHO KNOWS THE APPLICANT
MUST SUPPLY THE INFORMATION REQUESTED BELOW.
9. Signature of Witness10. Date Signed
/
/
11. Address of Witness
12. Remarks
According to the Paperwork Reduction Act 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 is 0938-1230. The time required to complete
this information is estimated to average 45 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, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard,
Baltimore, Maryland 21244-1850.
CMS-40B (04/17) 2
Form Approved
OMB No. 0938-1230
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
During the General Enrollment Period (GEP) from
January 1 through March 31 of each year
If you’re eligible for a Special Enrollment Period (SEP),
like if you’re covered under a group health plan (GHP)
based on current employment.
Initial Enrollment Period
Your IEP is the first chance you have to sign up for Part B.
It lasts for 7 months. It begins 3 months before the month
you reach 65, and it ends 3 months after you reach 65. If you
have Medicare due to disability, your IEP begins 3 months
before the 25th month of getting Social Security Disability
benefits, and it ends 3 months after the 25th month of
getting Social Security Disability benefits. To have Part B
coverage start the month you’re 65 (or the 25th month of
disability insurance benefits); you must sign up in the first 3
months of your IEP. If you sign up in any of the remaining 4
months, your Part B coverage will start later.
General Enrollment Period
If you don’t sign up for Part B during your IEP, you can sign
up during the GEP. The GEP runs from January 1 through
March 31 of each year. If you sign up during a GEP, your
Part B coverage begins July 1 of that year. You may have to
pay a late enrollment penalty if you sign up during the GEP.
The cost of your Part B premium will go up 10% for each
12-month period that you could have had Part B but didn’t
sign up. You may have to pay this late enrollment penalty as
long as you have Part B coverage.
Special Enrollment Period
If you don’t sign up for Part B during your IEP, you can
sign up without a late enrollment penalty during a Special
Enrollment Period (SEP). If you think that you may be eligible
for a SEP, please contact Social Security at 1-800-772-1213.
TTY users should call 1-800-325-0778 You can use a SEP when
your IEP has ended. The most common SEPs apply to the
working aged, disabled, and international volunteers.
Working Aged/Disabled
You have a SEP if you’re covered under a group health plan
(GHP) based on current employment. To use this SEP, you
must:
Be 65 or older and currently employed
Be the spouse of an employed person, and covered under
your spouse’s employer GHP based on his/her current
employment
Be under 65 and disabled, and covered under a large
group health plan (LGHP) based on your or your spouse’s
current employment, or the current employment of any
family member
You can sign up for Part B anytime while you have a GHP
coverage based on current employment or during the 8
months after either the coverage ends or the employment
ends, whichever happens first. If you sign up while you have
GHP coverage based on current employment, or, during the
first full month that you no longer have this coverage, your
Part B coverage will begin the first day of the month you
sign up. You can also choose to have your coverage begin
with any of the following 3 months. If you sign up during
any of the remaining 7 months of your SEP, your Part B
coverage will begin the month after you sign up.
NOTE: COBRA coverage or a retiree health plan is not
considered group health plan coverage based on current
employment.
International Volunteers
You have a SEP if you were volunteering outside of the
United States for at least 12 months for a tax-exempt
organization and had health insurance (through the
organization) that provided coverage for the duration of the
volunteer service.
Privacy Act Notice: The Social Security Administration (SSA) is authorized to collect the information under sections 1836, 1840 and 1872 of
the Social Security Act, as amended (42 U.S.C. 1395o, 1395s, and 1395ii). This information is needed for SSA and the Centers 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. The information you give can be shared for “routine
uses” published in the Federal Register. Because there are too many to list here, SSA can give you more information about this if you ask. The
information you give on this form may be verified by way of computer match (Pub. Law 100-503).
CMS-40B (04/17) 3
Form Approved
OMB No. 0938-1230
STEP BY STEP INSTRUCTIONS FOR FILLING OUT THIS APPLICATION
1. Your Social Security Claim Number:
Write your social security claim number in each of the
boxes. Include any letters following the claim number.
These are known as the Beneficiary Identification
Code (BIC).
2. Do you wish to sign up for Medicare Part B (Medical
Insurance)?
Mark “YES” in this field if you want to sign up for
Medicare Part B which provides you with medical
insurance under Medicare. You can only sign up using
this form if you already have Medicare Part A (Hospital
Insurance). If your answer to this question is “no”
then you don’t need to fill out this application. This
application is to sign up to get medical insurance under
Medicare.
If you don’t have Part A and want to sign up, please
contact Social Security at 1-800-772-1213. TTY users
should call 1-800-325-0778.
3. Name:
Write your name as you did when you applied for Social
Security or Medicare. List last name, first name and
middle name in that order. If you don’t have a middle
name, leave it blank.
4. Mailing Address:
Write your full mailing address including the number
and street name, P.O. Box, or route in this field.
5. City, State, and ZIP code:
Write the city name, state and ZIP code for the mailing
address.
6. Phone Number:
Write your 10-digit phone number, including area code.
7. Written Signature:
Sign your name in this section in the same way
you would sign it for any other official document.
Do not print.
If you’re unable to sign, you may mark an “X” in this
field. In this case, you will need a witness and the
witness must complete questions 11, 12 and 13.
8. Date Signed:
Write the date that you signed the application.
9. Signature of Witness:
In the case that question 9 is signed by an “X” instead
of a written signature, a witness signature is needed
in question 11 showing that the person who signs the
application is the person represented on the application.
10. Date Signed:
If a witness signs this application, the witness must
provide the date of the signature.
11. Address of Witness:
If a witness signs this application, provide the witness’s
address.
12. Remarks:
Provide any remarks or comments on the form to clarify
information about your enrollment application.
IMPORTANT INFORMATION:
Review the scenario below to determine if you need to include additional information or forms with your application.
If you’re signing up for Part B using a Special Enrollment Period (SEP) because you were covered under a group health plan
based on current employment, in addition to this application, you will also need to have your employer fill out and return
the “Request for Employment Information” form (CMS-L564/CMS-R-297) with your application. The purpose of this form is
to provide documentation to Social Security that proves that you have been continuously covered by a group health plan
based on current employment, with no more than 8 consecutive months of not having coverage. If your employer went out of
business or refuses to complete the form, please contact Social Security about other information you may be able to provide to
process your SEP enrollment request.
Send the application (and the “Request for Employment Information,” if applicable) to your local Social Security Office. Find
your local office at www.ssa.gov.
INSTRUCTIONS: CMS-40B (04/17) 4
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