CMS 40B | CMS
Summary: The CMS 40B form is used by individuals who already have Medicare Part A to apply for Medicare Part B (Medical Insurance) during their Initial Enrollment Period, General Enrollment Period, or a Special Enrollment Period.
This document is the official CMS-40B form (expires 07/31/2028) used to request enrollment in Medicare Part B. It is intended for individuals who are already enrolled in Medicare Part A. The form collects basic applicant information, details regarding employer or union group health plan coverage, and volunteer work history. It also allows applicants to select their preferred coverage start date if they are transitioning from employer-based coverage. The form must be submitted to a local Social Security office via mail or fax. It includes a Privacy Act Statement and instructions for obtaining assistance through Social Security or the State Health Insurance Assistance Program (SHIP).
Document outline
1. Section 1: Basic Information (Medicare Number, Name, Address, Phone, Email) 2. Section 2: Enrollment in Medicare Part B (Employer/Union coverage, International volunteer work, Employment dates, Coverage start date selection) 3. Section 3: Signature(s) (Applicant signature, Date, Witness signature if applicable) 4. Privacy Act Statement 5. Paperwork Reduction Act Notice