CMS-18F5 Application for Part A (Hospital Insurance)

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

Form Approved
OMB No. 0938-xxxx
Expires: xx/xx

APPLICATION FOR PART A (HOSPITAL INSURANCE)
WHO CAN USE THIS APPLICATION?
People age 65 and older (and those turning 65 in the next 3 months) who want to apply for Part A. Part A covers hospital care
and more.
NOTE: If you or your spouse works for a railroad or gets railroad benefits, call the Railroad Retirement Board (RRB) at
1-877-772-5772.

WHEN DO YOU USE THIS APPLICATION?
Use this form:
• If you’re eligible for Social Security benefits but only want to get Medicare. You must at least 64 and 8 months. (You won’t
pay a premium for Part A.)
• If you’re not eligible for Social Security benefits and want to sign up for Part A. You can sign up only during certain times—
see next page.
(You’ll pay a premium for Part A.)
NOTE: Because you’re signing up for Part A, you can also sign up for Part B (Medical Insurance) with this form. Part B covers
doctors’ services and more.

WHAT INFORMATION DO YOU NEED TO COMPLETE THIS APPLICATION?
You will need your
•
•
•
•
•

Social Security Number
Date of birth
Current address and phone number
Work history
Form CMS-L564 “Request for Employment Information” completed by your employer if you’re signing up for Part A (and
have to pay a premium for it) or Part B during a Special Enrollment Period.

WHAT HAPPENS NEXT?
Send your completed and signed form (pages 3-4) to your local Social Security office. If you have questions, call Social Security
at 1-800-772-1213. TTY users can call 1-800-325-0778.

HOW DO YOU GET HELP WITH THIS APPLICATION?
•

Phone: Call Social Security at 1-800-772-1213.
TTY users can call 1-800-325-0778.
• In person: Visit your local Social Security office. Find an office near you at www.ssa.gov.
• 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.

HEALTH SAVINGS ACCOUNT (HSA)
If you’re applying after reaching the age of 65, you must stop contributing to your HSA before applying for Medicare to
avoidIRS penalties. Premium-free Part A coverage starts up to 6 months back from when you apply (but not earlier than the
month you turned 65). Visit www.irs.gov for more on HSAs.

REMINDER
If you have to pay a premium for Part A, or if you also sign up for Part B, you must pay premiums for every month you have
the coverage.

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

Form Approved
OMB No. 0938-xxxx
Expires: xx/xx

When you can apply for Part A (if you have to pay a premium for it) and Part B
WHEN YOU’RE FIRST ELIGIBLE
(Initial Enrollment Period)
This is the first chance you have to apply. It lasts for 7 months. It begins 3 months before the month you turn 65, and it ends
3 months after you turn 65. To have your Part A or Part B coverage start the month you turn 65, sign up during the 3 months
before you turn 65. If you wait until the month you turn 65 (or the 3 months after you turn 65) to apply, your coverage will be
delayed.

JANUARY 1-MARCH 31 EACH YEAR
(General Enrollment Period)
If you sign up during this time, your coverage will start July 1. In most cases, you’ll have to pay a late enrollment penalty. The
penalty is added to your monthly premium, and it goes up the longer you go without coverage.
•
•

Part A penalty: If you have to pay a premium for Part A, your premium will go up 10%. You’ll pay it for twice the number
of years you didn’t sign up.
Part B penalty: Your B premium will go up 10% for each 12-month period that you could have had Part B but didn’t sign
up. You’ll pay it for as long as you have Part B coverage.

SPECIAL SITUATIONS
(Special Enrollment Period)
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 GHP based on your own or your spouse’s current employment
You can sign up 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 coverage will begin the first day of
the month you sign up. You can also choose to have your coverage begin within any of the following 3 months. If you sign up
during any of the remaining 7 months of your SEP, your 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.
If you think you may be eligible for a Special Enrollment Period, contact Social Security at 1-800-772-1213. TTY users can call
1-800-325-0778.
Visit Medicare.gov to learn more about when you can sign up and special situations for people under 65 with a disability

You have the right to get Medicare information in an accessible form, like large print, Braille, or audio. You also have the right to
file a complaint if you feel you’ve been discriminated against. Visit Medicare.gov/about-us/accessibility-nondiscrimination-notice,
or call 1-800-MEDICARE (1-800-633-4227) for more information. TTY users can call 1-877-486-2048.

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Form Approved
OMB No. 0938-1230
Expires: xx/xx

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

APPLICATION FOR PART A (HOSPITAL INSURANCE)
1. TELL US ABOUT YOURSELF: We need this information to find you in our records.
1a. Your Social Security Number (or your Medicare Number, if 1b. Your Name (Last Name, First Name, Middle Name)
you already have Part B )

/

/

1c. Name at Birth if different than item 1b

1d. Sex
Male

1e. Date of Birth (MM/DD/YYYY)

/

Female

/

1f. State or Country of Birth (NO abbreviations)

1g. Mailing Address (Number and Street, P.O Box, or Route)

1h. Address of permanent residence, if different from your
mailing address

1i. Phone Number

(

)

–

2. TELL US ABOUT YOUR WORK HISTORY:
2a. How much were your total earnings last year? If none, write “NONE.”
2b. How much do you expect your total earnings to be this
year? If none, write “NONE.”

2c. Did you work in the railroad industry after January 1, 1937?
Yes
No

3. TELL US ABOUT YOUR CITIZENSHIP:
3a. Are you a United States citizen? (If yes, go to item 4.)

Yes

No

3b. Are you lawfully present in the U.S.? (If no, go to item 4.)
Yes
No

3c. When did you become lawfully present in the U.S.? (MM/DD/YYYY)

3d. Are you currently a resident of the U.S.?

3e. When did you become a resident of the U.S.? (MM/DD/YYYY)

Yes

/

No

/

/

3f. Have you resided in the U.S. without a break for the past 5 years?

/

Yes

No

3g. Enter where you lived for the last 5 years and the dates you lived there.
Address
Started living there

/
3h. Have you been outside the U.S. in the last 5 years?

Stopped living there

/
Yes

/

/

No

4. TELL US ABOUT YOUR MARITAL STATUS:
4a. Are you currently married?

Yes

No

4b. Spouse’s name (last name, first name, middle name)

4c. Spouse’s Date of Birth (MM/DD/YYYY)

4d. Spouse’s Social Security Number

4e. Date of marriage (MM/DD/YYYY)

4f. If you are not married now, did you have a former marriage that lasted 10
or more years OR ended in death?
(If no, go to item 10.)
Yes
No

/

/

/

/

/

/

4g. Name of former spouse (last name, first name, middle
name)

4h. Former spouse’s date of birth (MM/DD/YYYY)

4i. Spouse’s Social Security Number

4j. Date of former marriage (MM/DD/YYYY)

/

/

4k. Date former marriage ended (MM/DD/YYYY)

/

/

/
/

/

4l Date of former spouse’s death, if deceased (MM/DD/YYYY)

/

4m. Do you have another marriage that lasted 10 years or ended in death?

CMS-18-F-5 (11/20)

/

/
Yes

No

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5. ENROLLMENT IN PREMIUM PART A AND PART B:
5a. If you have to pay a premium for Part A, do you still want to get Part A? (If “Yes”, You must also sign up for Part B, and you have to pay
monthly premiums.)
Yes
No
Yes

5b. Do you want to sign up for Part B? (You pay a monthly premium for Part B.)

No

6. TELL US ABOUT YOUR CURRENT OR PRIOR HEALTH COVERAGE AND BENEFITS:
We need this information to determine when you can sign up and your premiums.
Yes

6a. Do you have Medicaid? (People with Medicaid can get help paying their premiums. If yes, go to item 7.)

No

6c. Are you currently (or were you) an international volunteer for a nonprofit organization and have or had health coverage provided to you? (If
yes, complete item 6d.)
Yes
No

6b. Do you currently have (or did you have) coverage through an
employer or union group health plan? (If yes, complete item 6d.)
Yes
No

6d. Enter dates of employment (or volunteer work) and health coverage (Enter all dates as MM/DD/YYYY)
Dates you (or your spouse) worked for
employer that provided health coverage:
Start Date:

/

Ending Date:

/

Dates of health coverage from employer Dates you worked as a volunteer
(or non-profit organization):
outside the U.S.:

/

Start Date:

/

/

Ending Date:

/

Not ended

/

Start Date:

/

/

Ending Date:

/

Not ended

/
/
Not ended

6e. Are you (or your spouse) currently getting retirement benefits from the Office of Personnel Management (OPM)? (If no, go to item 7.)
No
Yes
6f. Your OPM retirement claim number

6g. Your spouse’s OPM retirement claim number

6h. Do you want to have your Part B premiums deducted from your spouse’s retirement benefits? (See instructions on page 8 before you
answer.)
Yes
No

7. SIGN YOUR APPLICATION:
7a. If you are completing this application for someone else, what’s your name and your relationship to the person applying?
By signing this application, I understand that the information I entered will be used to process my application for Medicare. I understand that if I intentionally provide false information on this form, it is a crime punishable under Federal law by fine, imprisonment, or both. I declare under penalty of perjury that
the information I entered is true and correct to the best of my knowledge.
7b. Written signature (Do not print)

7c. Date Signed

/

/

If this application has been signed by mark (X), a witness who knows the person applying must also sign this form.
7d. Name of witness (first and last name)
7e. Signature of witness

7f. Date Signed

/

/

7g. Extra Space for items 3g and 6d, if needed

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

Date Signed

/

/

Printed Name of Witness
Signature of Witness

CMS-18-F-5 (11/20)

Date Signed

/

/
4

PRIVACY ACT STATEMENT: Social Security is authorized to collect your information under sections 1836, 1840, and 1872 of the
Social Security Act, as amended (42 U.S.C. 1395o, 1395s, and 1395ii) for your enrollment in Medicare Part B. Social Security and
the Centers for Medicare & Medicaid Services (CMS) need your information to determine if you’re entitled to Part B. While
you don’t have to give your information, failure to give all or part of the information requested on this form could delay your
application for enrollment.
Social Security and CMS will use your information to enroll you in Part B. Your information may be also be used to administer
Social Security or CMS programs or other programs that coordinate with Social Security or CMS to:
1. Determine your rights to Social Security benefits and/or Medicare coverage.
2. Comply with Federal laws requiring Social Security and CMS records (like to the Government Accountability Office and the
Veterans Administration).
3. Assist with research and audit activities necessary to protect integrity and improve Social Security and CMS programs (like
to the Bureau of the Census and contractors of Social Security and CMS). We may verify your information using computer
matches that help administer Social Security and CMS programs in accordance with the Computer Matching and Privacy
Protection Act of 1988 (P.L. 100-503)
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-XXXX. The
time required to complete this information is estimated to average XX 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, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
IMPORTANT
Do not send this form or any items with your personal information (such as claims, payments, medical records, etc.) to the
PRA Reports Clearance Office. Any items we get that aren’t about how to improve this form or its collection burden (outlined
in OMB 0939-XXXX) will be destroyed. It will not be kept, reviewed, or forwarded to Social Security or any other agency. See
“What happens next?” on page 1 to send your completed form to Social Security.

CMS-18-F-5 (11/20)

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STEP BY STEP INSTRUCTIONS FOR 18-F
1. TELL US ABOUT YOURSELF
a. Your Social Security Number (or your Medicare
Number): Enter your Social Security Number, or if you
already have Medicare, you can enter your Medicare
Number instead.
b. Name: Enter your name. List your last name, first name,
and middle name (if you have one) in that order.
c. Name at birth: If your name in 1b is different from your
name at birth, enter the name you were given at birth.
List your last name, first name, and middle name (if you
have one) in that order.
d. Sex: Select one: male or female
e. Date of birth: Enter your date of birth as MM/DD/YYYY.
f. State or country of birth: Enter the state or foreign
country where you were born. Spell out the location;
don’t use abbreviations.

e. When did you become a resident of the U.S.? Enter the
date when both of these first applied: you had lawful
presence status and you were living in the U.S. Enter the
date as MM/DD/YYYY.
f. Have you resided in the U.S. without a break for the
last years? Select one: yes or no.
g. Enter where you lived for the last 5 years and the dates
you lived there: List the addresses and dates for places
you lived for the last 5 years. List the most recent place
you lived (or currently live) first. Enter the date you
started living at each place, even you moved there more
than 5 years ago. Enter dates as MM/DD/YYYY. If you
need more space, add the information in item 7g.
h. Have you been outside the U.S. in the last 5 years?
Select one: yes or no.

4. MARITAL Status

g. Mailing address: Enter your full mailing address,
including the number and street name, city, state, and
ZIP code. You can enter a P.O. Box or route.

a. Are you currently married? Select one: yes or no. If
you’re divorced or your spouse is deceased, select no,
skip items 4a-4e and go to item 4f If you’ve never been
married, skip items 4a-4m and go to item 5.

h. Address of permanent residence: If you live at a
different address than where you get mail, enter the
full address, including the number and street name, city,
state and ZIP code.

b. Name of spouse: Enter your current spouse’s name.
List as last name, first name, and middle name (if your
spouse has one) in that order.

i. Phone number: Enter your 10-digit phone number,
including your area code.

2. EARNINGS
a. How much were your total earnings last year? Enter the
total amount of your W2 wages and net earnings for the
prior year. If you don’t have any earnings, enter “None.”
b. How much do you think your total earning will be this
year? Enter the total amount you expect your W2 wages
and net earnings will be for this year. If you don’t have
any earnings, enter “None.”
c. Did you work for a railroad after January 1, 1937?
Select one: yes or no. If you select yes, you may have to
contact the Railroad Retirement Board at
1-877-772-5772.

3. CITIZENSHIP?
a. Are you a United States citizen?
Select one: yes or no. If you select yes, skip items 3b-3g
and go to item 4. If you select no, complete items 3b-3g.
If you don’t qualify to get Part A without paying a
premium based on your work earnings or a spouse’s
work earnings, you may be able to sign up for Part A if
you have your green card (lawful permanent residence)
and have resided in the U.S. without a break for the last
5 years. You’ll have to pay a monthly premium for it.
b. Are you lawfully present in the U.S.? Select one: yes or
no. To learn more about lawful presence, visit www.dhs.
gov/how-do-i/get-green-card. If you select no, skip items
3c-3h and go to item 4.
c. When did you become lawfully present in the U.S.?
Enter the date you got your lawfully present status.
Enter the date as MM/DD/YYYY.

c. Spouse’s date of birth: Enter the date of birth for your
current spouse. Enter the date as MM/DD/YYYY.
d. Spouse’s Social Security Number: Enter the Social
Security Number of your current spouse. If you don’t
know it, enter “Unknown.”
e. Date of marriage: Enter the date you married your
current spouse. Enter the date as MM/DD/YYYY.
f. Former Spouse. Select one: yes or no. If you select no,
continue to number 5.
g. Name of former spouse: Enter your former spouse’s
name. If your spouse is deceased or if you’re divorced,
enter the name here.
h. Former spouse’s date of birth: Enter the date of birth
for your former spouse. Enter the date as MM/DD/YYYY.
i. Former spouse’s Social Security Number: Enter the Social
Security Number of your former spouse. If you don’t
know it, enter “Unknown.”
j. Date of former marriage: Enter the date you married
your former spouse. Enter the date as MM/DD/YYYY.
k. Date former marriage ended: Enter the date your former
marriage ended due to divorce. If you’re divorced and
your former spouse is deceased, also answer item 4L.
Enter the date as MM/DD/YYYY.
l. Date of former spouse’s death: If your spouse is
deceased, end your spouse’s date of death. Enter the
date as MM/DD/YYYY.
m. Does your spouse (or did your spouse) work for a
railroad or get railroad benefits? Select one: yes or no.

d. Are you currently a resident of the U.S.? Select one: yes
or no.

INSTRUCTIONS: CMS-18-F-5 (11/20)

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5. ENROLLMENT IN PREMIUM PART A AND PART B:
a. If you have to pay a premium for Part A, do you still
want to get Part A? Select one: yes or no. If you don’t
qualify to get Part A without having to pay a premium,
you can choose whether you still want to sign up for
Part A.
• If you select yes, you must also sign up for Part B, and you
have to pay monthly premiums for both Part A and Part
B. Visit Medicare.gov for current premium costs.
• If you select no, you won’t get Part A or Part B.

b. Do you want to sign up for Part B?
Select one: yes or no. If you’re applying for Medicare for
the first time, you can choose whether you also want to
sign up for Part B (Medical Insurance).
• If you select yes and you’re in one of the enrollment
periods listed on page 2 of this form, you’ll get Part B.
Social Security will tell you when you Part B coverage
will start. You’ll pay a monthly premium for Part B. Visit
Medicare.gov for Part B costs.
• If you select no and you qualify for Part A without having
to pay a premium, you’ll just get Part A.
• If you don’t qualify for Part A without having to pay
a premium and you want to buy Part A, you must also
select yes to this item. In order to buy Part A, you must
also get Part B.

6. CURRENT OR PRIOR HEALTH COVERAGE AND BENEFITS:
a. Do you have Medicaid? Select one: yes or no. Medicaid
is a state program that helps pay medical costs for some
people with limited income and resources. If you meet
certain conditions or have Medicaid, you can get help
paying their premiums. Visit Medicare.gov for more on
getting help paying costs.
b. Do you currently have (or did you have) coverage
through an employer or union group health plan? Select
one: yes or no. A group health plan is generally a health
plan offered by an employer or employee organization
that provides health coverage to employees and their
families. If you select yes, complete item 6d.
c. Are you currently (or were you) an international
volunteer for a non-profit organization and also have
health coverage by that organization? Select one: yes or
no. For more information about international volunteers
see the note on page 2. If you select yes, complete item
6d.
d. Enter dates of employment (or volunteer work) and
health coverage: Only complete this item if you selected
yes to item 6b or 6c. You only need to enter any work
and health coverage you had since you turned 65.
• If you selected yes to item 6b, enter information about
your (or your spouse’s) employer health coverage. You
need to list both the dates you (or your spouse) worked
for the employer that provided your health coverage
in the first column in the chart, and the dates you had
health coverage in the second column in the chart.
• If you selected yes to item 6c, enter information about
your health coverage while you were volunteering
outside the U.S. You need to list both the dates you
volunteered for the non-profit organization that provided
your health coverage in the third column in the chart,
and the dates you had health coverage in the second
column in the chart.

e. Are you (or your spouse) currently getting retirement
benefits from the Office of Personnel Management
(OPM)? Select one: yes or no. It’s also called a civil
service annuity. If you select no, skip items 6e-6h, and go
to item 7.
f. Your OPM retirement claim number: Enter your full OPM
retirement claim number. They’re also known as CSA
and CSF numbers. Include all the letters and numbers
for your official OPM claim number. You can find your
number on your retirement card, annuity payment
statements, welcome letter, or 1099-R tax form from
the Office of Personnel Management. Visit OPM.gov for
more on how to find your claim number.
g. Your spouse’s OPM retirement claim number: Enter your
spouse’s full OPM retirement claim number.
h. Do you want to have your Part B premiums deducted
from your spouse’s retirement benefits?
Select one: yes or no. In order to select yes, all of these
must apply:
• You’re not getting or applying for Social Security benefits
• You’re not eligible to have the state pay your Medicare
premium
• Your spouse also has Part B and has Part B premiums
deducted from their monthly retirement benefit
• Your spouse provides written consent to have your Part
B premiums deducted from their monthly retirement
benefit

7. SIGNING YOUR APPLICATION
a. If you are completing this application for someone else,
what’s your name and your relationship to the person
applying? Enter your full name (first, middle, and last
name) and your relationship to the person applying for
Part A.
b. Written signature: Sign your name 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’ll need a witness and the witness
must complete items 7a-7c.
c. Date signed: Enter the date that you signed the
application.
d. Name of witness: Enter the full name (first, middle, and
last name) of the witness.
e. Signature of witness: The witness signs their name in
this field. Sign it in the same way you would sign it for
any other official document. Do not print. The witness’
signature verifies that you are the person applying for
Part A and that you signed the application.
f. Date signed: Enter the date that the witness signed the
application.
g. Extra Space: If you have more to list than the space
provided for items 3f and 6d, enter it in this field.

Enter both the start and end dates for each item. If it
hasn’t ended yet, select “Not ended.” Enter all dates
as MM/DD/YYYY. If you need more space, add the
information in item 7g.
INSTRUCTIONS: CMS-18-F-5 (11/20)

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