CMS-40B Application for Enrollment in Medicare Part B (Medical I

Form Approved
OMB No. 0938-1230
Expires: 04/24

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

APPLICATION FOR ENROLLMENT IN MEDICARE PART B (MEDICAL INSURANCE)
WHO CAN USE THIS APPLICATION?

WHAT HAPPENS NEXT?

People with Medicare who have Part A(hospital insurance)
but not Part B

Send your completed and signed application to your local
Social Security office. If you have questions, call Social
Security at 1-800-772-1213. TTY users should call
1-800-325-0778.

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:

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.

•

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.

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 https://www.ssa.gov/locator.

•

If you’re eligible for a Special Enrollment Period (SEP).

•

If you’re in your Initial Enrollment Period (IEP) and live in
Puerto Rico. You must sign up for Part B using this form.

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?

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.
You may have to pay this LEP as long as you have Part B
coverage.

You will need:
• Your Medicare Number
•

Your current address and phone number

You have the right to get Medicare information in an accessible format, like large print, braille, or audio. You also have the
right to file a complaint if you feel you’ve been discriminated against. Visit https://www.medicare.gov/about-us/accessibilitynondiscrimination-notice, or call 1-800-MEDICARE (1-800-633-4227) for more information. TTY users can call 1-877-486-2048.
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 0938-1230. The time required to complete
this information 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. As authorized, we may use and disclose this information in computer matching programs, in which our
records are compared with other records to establish or verify a person’s eligibility for Federal benefit programs and for repaying of incorrect
or delinquent debts under these programs.

CMS-40B (11/23)

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Form Approved
OMB No. 0938-1230
Expires: 04/24

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

APPLICATION FOR ENROLLMENT IN MEDICARE PART B (MEDICAL INSURANCE)
1. Your Medicare Number
2. Your Name (Last Name, First Name, Middle Name)

3. Mailing Address (Number and Street, PO Box, or Route)
4. City

State

5. Phone Number (Including Area Code)

Zip Code

(

6. Do you wish to sign up for Medicare Part B (Medical Insurance)?

)

–

YES

7a. Do you currently have (or did you have) coverage through an employer or union group health plan?
(If yes, complete 7c.)
YES
NO
7b. Are you currently (or were you) an international volunteer for a non-profit organization and have or had health coverage
YES
NO
provided to you? (If yes, complete 7c.)
7c. Enter dates of employment (or volunteer work) and health coverage below. (Enter all dates as MM/YYYY)
Dates you (or your spouse) worked for
employer that provided health coverage:
Start Date:
Ending Date:

Dates of health coverage from employer (or
non-profit organization):

/

Start Date:

/

Ending Date:

Not ended

Dates you worked as a volunteer outside
the U.S.:

/

Start Date:

/

Ending Date:

Not ended

/
/
Not ended

8. Has an employer, health insurance provider, or other entity requested or required you to enroll in Part B? (If yes, explain
how and why in the Remarks section, and include proof or documentation with this form.)
YES
NO
9. Remarks:

10. Written Signature (DO NOT PRINT)

SIGN HERE

11. Date Signed

/

/

IF THIS APPLICATION HAS BEEN SIGNED WITH A MARK OR AN (X), A WITNESS WHO KNOWS
THE APPLICANT MUST SUPPLY THE INFORMATION REQUESTED BELOW.
12. Signature of Witness

13. Date Signed

/

/

14. Address of Witness (Street Number and Name, City, State, Zip)

CMS-40B (11/23)

2

Form Approved
OMB No. 0938-1230
Expires: 04/24

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).

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 the month after you sign up. 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 GHP
based on your own or your spouse’s current employment
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.
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.
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.

CMS-40B (11/23)

3

Form Approved
OMB No. 0938-1230
Expires: 04/24

STEP BY STEP INSTRUCTIONS FOR FILLING OUT THIS APPLICATION
1.

Your Medicare Number:
Write your Medicare number.

2.

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.

3.

Mailing Address:
Write your full mailing address including the number and
street name, PO Box, or route in this field.

4.

City, State, and ZIP code:
Write the city name, state, and ZIP code for the mailing
address.

5.

Phone Number:
Write your 10-digit phone number, including area code.

6.

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.

7a. 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 7c.
7b. 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 7c.

(7c. continued)
If you selected YES to item 7b, 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. Enter both the start and end
dates for each item. If it hasn’t ended yet, select “NOT
ENDED.” Enter all dates as MM/YYYY. If you need more
space, add the information in the Remarks section of
question 9.
8.

Do you currently have (or had) an employer or entity
that has requested (or requires) you to enroll into Part B?
Select one: YES or NO. If you selected YES, indicate it in
remarks section of question 9. Send documentation with
this form.

9.

Remarks:
Provide any remarks or comments on the form to clarify
information about your enrollment application.

10. 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 12, 13 and 14.
11. Date Signed:
Write the date that you signed the application.
12. Signature of Witness:
In the case that question 10 is signed by an “X” instead
of a written signature, a witness signature is needed
showing that the person who signs the application is the
person represented on the application.
13. Date Signed:
If a witness signs this application, the witness must
provide the date of the signature.
14. Address of Witness:
If a witness signs this application, provide the witness’s
address.

7c. Enter dates of employment (or volunteer work) and
health coverage: Only complete this item if you selected
YES to item 7a or 7b. You only need to enter any work
and health coverage you had since you turned 65. If you
selected YES to item 7a, 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.

INSTRUCTIONS: CMS-40B (11/23)

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