Crosswalk

Revisions to Form CMS 40B (OMB 0938-1230) Application for Enrollment in Medicare Part B (Medical Insurance)
The form was updated to add questions related to a respondents Special Enrollment Period (SEP). There were no statutory or
regulatory changes. The form changes affected the burden as outlined in the Supporting Statement A.
Changes

Question

Updated Form

Original Form

Reason for Change

Page 2- Application

Q1. Your Medicare
Number
Q2. Your Name

Q1. Your Medicare
Number
Q2. Do you wish to
enroll in Part B?
Q3. Your Name

N/A

Burden
Effect
N/A

Moved to question 6.

N/A

Moved to question 2.

N/A

Q4-6. Mailing Address
and phone number
Q7 Written Signature

Moved to questions 3-5.

N/A

Moved to Q10.

Burden
increased
from 5
minutes to
10 minutes
to account
for the
addition of
new
questions.
The new
questions
were
developed

Q3-5 Mailing address
and phone number
Q6 Do you wish to
enroll in Part B?
Q7a. Do you currently
have (or did you have)
coverage through an
employer or union
group health plan? (If
yes, complete 7c.)
Q7b. Are you currently
(or were you) an
international volunteer
for a non-profit
organization and have
or had health coverage

provided to you? (If yes,
complete 7c.)
Q7c. Enter dates of
employment (or
volunteer work) and
health coverage below.
(Enter all dates as
MM/YYYY)
Q8. Do you currently
have (or did you have)
an employer or entity
that has requested (or
requires) you to enroll
into Part B? (If yes,
indicate it in the
remarks section and
send the
documentation with
this form.)

Q9. Remarks
Q10-11. Signature and
date of applicant.

to assist
technicians
in
processing
enrollments
efficiently.

Q8. Date

Moved to Q11.

Q9-11. Signature, date,
and address of witness

Moved to Q12-14.

Burden
increased
from 5
minutes to
10 minutes
to account
for the
addition of
new
questions.
The new
questions
were
developed
to assist
technicians
in
processing
enrollments
efficiently.
N/A

N/A

N/A

Q12-14 Signature, date,
and address of witness

Q12. Remarks

Moved to Q9.

N/A