CMS-4040 Request for Enrollment in Supplementary Medical Insuranc

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

Form Approved
OMB No. 0938-0245 (Expires: TBD)

TOE 810

DO NOT WRITE IN THIS SPACE

REQUEST FOR ENROLLMENT IN
SUPPLEMENTARY MEDICAL INSURANCE
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 supplementary medical insurance under title XVIII of the Social Security Act, as presently amended. I
understand that a premium payment is due for each month of coverage. (See reverse side for information about paying the medical
insurance premium.)

1.

a. PRINT your name

First Name, Middle Initial, Last Name

b. Enter your name at birth if different from 1(a)

2.

c. Enter your sex (check one)

❏ Male ❏ Female

d. Enter your Social Security Number

__ __ __ / __ __ / __ __ __ __

a. Enter your date of birth (Month, day, year)
b. Enter name of State or foreign country where you were born

3.
4.

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

Have you ever before enrolled for supplementary medical
insurance under Medicare?

❏ Yes ❏ No ❏ Unknown

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?
(If “Yes,” answer (b). If “No,” go on to item 5.)
b. Enter the Civil Service annuity number here.
(Include the prefix, i.e., “CSA” for annuitant, “CSF” for survivor.)
If you entered your spouse’s number, is he (she) enrolled for
supplementary medical insurance?

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❏ Yes ❏ No ❏ Unknown
Your No.
Spouse’s No.

❏ Yes ❏ No ❏ Unknown
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If you are entitled to Medicare’s hospital insurance omit items 5 and 6.
5.

Are you a resident of the United States?
(To reside in a place means to make a home there.)

❏ Yes ❏ No

6.

a. Are you a citizen of the United States?
((If “Yes,” omit items b. and c. If “No,” answer b. and c. below.)

❏ Yes ❏ No

b. Are you lawfully admitted for permanent residence in the
United States?

❏ Yes ❏ No

c. Enter below the information requested about your place of residence in the last 5 years.
ADDRESSES AT WHICH YOU RESIDED IN THE LAST 5 YEARS

(Begin with the most recent address. Show actual date residence began even if that is prior to the last 5 years.)

DATE RESIDENCE BEGAN

DATE RESIDENCE ENDED

Month

Month

Day

Year

Day

Year

(If you need more space, use the “Remarks” space or another sheet of paper)

PAYING YOUR MEDICAL INSURANCE PREMIUM

Once you are enrolled in medical insurance, you must pay a standard monthly premium each month. Your premium may be higher
than the standard premium if you enroll in medical insurance more than 3 months after you turn age 65. If you wait more than 3
months after you turn age 65 to enroll in medial insurance, you can do so only during the General Enrollment Period that occurs
January through March of each year. Your medical insurance coverage will begin July of the year you enroll. The standard monthly
premium will be increased 10% for each full 12-month period you could have had medial insurance but didn’t take it.
Your premium will be deducted from any monthly Social Security, Railroad Retirement, or Office of Personnel Management benefit
check you receive. If you do not receive any of these benefits, you will be notified how to pay your premiums. You will receive
advance notice if there is any change in your premium amount.
Remarks

I know that anyone who makes or causes to be made a false statement or representation of material fact in an application or
for use in determining a right to payment under the Social Security Act commits a crime punishable under Federal law by
fine, imprisonment or both. I affirm that all information I have given in this document is true.
SIGNATURE OF APPLICANT

Signature

Date

(First Name, Middle Initial, Last Name) Write in Ink

Telephone Number

S I G N
H E R E

Mailing Address

(Number and Street, Apt No., P.O. Box or Rural Route)

City

State

ZIP Code

Name of Country (if any) in which you now live

Witnesses are required ONLY if this application has been signed by mark (✘) above. If signed by mark (✘), two witnesses to the
signing who know the applicant must sign below, giving their full addresses.
1. Signature of Witness

2. Signature of Witness

Mailing Address

Mailing Address

(Number and Street, Apt No., P.O. Box or Rural Route)

(Number and Street, Apt No., P.O. Box or Rural Route)

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 0938-0245. 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, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.
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