Form CMS-43 Application for Hospital Insurance Benefits for Individu

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

Form Approved
OMB No. 0938-0080
Expires: xx/xx

Application for Part A (Hospital Insurance) and
Part B (Medical Insurance) for People With End-Stage Renal Disease
Use this application to apply for Medicare no matter how old you are if you have End-Stage
Renal Disease (ESRD) and all of these apply:
• Your kidneys no longer work
• You need regular dialysis or have had a kidney transplant
Get more information about Medicare for people with ESRD at medicare.gov/basics/end-stagerenal-disease.

You must submit evidence to show you have ESRD
You’ll need to submit evidence with your application to show you’ve been diagnosed with EndStage Renal Disease (ESRD). Your provider needs to complete form CMS-2728-End-Stage Renal
Disease Medical Evidence Report Medicare Entitlement and/or Patient Registration. Submit the
completed form with your application. Download the form at cms.gov/Medicare/CMS-Forms/
CMS-Forms/Downloads/CMS2728.pdf.

How to submit this application
Send your completed and signed application and form CMS-2728 from your provider to your
local Social Security office by fax or mail. Visit www.ssa.gov/locator to get their contact
information.

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 SSA.gov/locator.
• 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.

Get information in another format
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.

CMS-43 (xx/xx)

1

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

Form Approved
OMB No. 0938-0080
Expires: xx/xx

When you can apply for Part A (Hospital Insurance) and Part B (Medical Insurance)
When you’re first eligible
You can be entitled to Medicare on the basis of ESRD no earlier than the month in which the
following requirements are met:
• You’ve worked long enough under Social Security or the Railroad Retirement Board, or
• You’re the spouse or dependent child of a person who meets either of the requirements
above.
NOTE: You must file an application, CMS-43 Application for Part A (Hospital Insurance) and
Part B (Medical Insurance) for People with End-Stage Renal Disease. The application may be
retroactive for up to 12 months. A medical determination is required to show that you have
ESRD and meet the transplant or regular dialysis requirements.

Special messages
• If you have group health plan coverage based on your or a family member’s employment or
former employment, and you’re eligible for Medicare because of ESRD, your group health
plan pays first for the first 30 months after you become eligible for Medicare. Medicare pays
first after this 30-month period.
• Medicare Part A (Hospital Insurance) helps cover your inpatient care in hospitals. Medicare
Part B (Medical Insurance) pays for most of the costs of physicians’ and surgeons’ services,
and other covered medical services such as OUTPATIENT DIALYSIS TREATMENTS, which are
not covered by Medicare Part A. Medicare Part B covers HOME DIALYSIS, including home
dialysis equipment and supplies.
• If you enroll in Medicare Part B, you will have to pay a monthly premium. Your premium will
be deducted from any monthly Social Security, Railroad Retirement, or Office of Personnel
Management benefit payment you receive. If you do not receive such benefits, you will be
notified about how to pay your premiums. You will receive advanced notice if there is any
change in your premium amount.
• Medicare generally can only pay for any of your hospital or medical bills when you receive
your medical care in the United States (including Puerto Rico, the Virgin Islands, Guam, the
Northern Mariana Islands and American Samoa).
If you only have Medicare because of End-Stage Renal Disease (ESRD), your Medicare coverage,
including immunosuppressive drug coverage, ends 36 months after a successful kidney
transplant. Medicare offers a benefit that helps you pay for your immunosuppressive drugs
beyond 36 months. This benefit only covers your immunosuppressive drugs and no other items
or services. It isn’t a substitute for full health coverage. If you sign up for the immunosuppressive
drug benefit, but get other health coverage later, you must notify Social Security within 60 days
of enrolling in the new coverage. You can sign up for this benefit at any time. To sign up, call
Social Security at 1-877-465-0355. This is a special phone number just for this benefit. TTY users
can call our general line at 1-800-325-0778

CMS-43 (xx/xx)

2

Form Approved
OMB No. 0938-0080
Expires: xx/xx

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

Application for Part A (Hospital Insurance) and
Part B (Medical Insurance) for People With End-Stage Renal Disease
1. TELL US ABOUT YOURSELF: We need this information to find you in our records.
1a. Your Social Security Number (or your Medicare Number)
1b. Your name (last name, first name, middle name)
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 (spell out - no abbreviations)

1g. Mailing address (number and street, PO Box, or route)

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

1i. Phone number

(

)

–

2. TELL US ABOUT YOUR EARNINGS AND WORK HISTORY:
2a. How much were your total earnings last year? Enter the total amount of your W2 wages and net earnings. If none, write “NONE.”
2b. How much do you expect your total earnings to be this
year? If none, write “NONE.”

2c.Did you or your spouse (or former spouse) work in the railroad industry for
5 years or more? (If no, skip the marriage questions in item 4.)
Yes
No

2d. Are you a dependent child using your parent’s work history or Social Security/Railroad Retirement Board insured status to qualify for ESRD
benefits?
Yes
No If yes, complete the following:
Mother’s name:

Father’s name:

/

DOB:

/

/

/
/
SSN:
or
Railroad Retirement Board (RRB) Number:

/
/
SSN:
or
Railroad Retirement Board (RRB) Number:
/

/

DOB:

/

/

2e. Have either of your parents worked in the railroad industry for 5 years or more?

/
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. (If you need more space, add the information to the remarks
space in Section 7.)
Address
Started living there (MM/YYYY)
Stopped living there (MM/YYYY)

/
Address

Started living there (MM/YYYY)

Address

Started living there (MM/YYYY)

Address

Started living there (MM/YYYY)

/
/
/

CMS-43 (xx/xx)

/
Stopped living there (MM/YYYY)

/
Stopped living there (MM/YYYY)

/
Stopped living there (MM/YYYY)

/

3

4. TELL US ABOUT YOUR MARITAL STATUS:
NOTE: Complete this section only if you’re using your spouse or former spouse’s work record or Social Security/Railroad Retirement Board
insured status to qualify for Medicare.
4a. Are you currently married? (If no, go to item 4g.)
Yes
No
4c. Spouse’s date of birth (MM/DD/YYYY)

/

4b. Spouse’s name (last name, first name, middle name)
4d. Spouse’s Social Security Number

/

/

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

/

/

/

4f. Does your spouse (or did your spouse) work for a railroad or get railroad
benefits?
Yes
No

4g. If you’re not married now, did you have a former marriage that lasted 10 or more years OR ended in death? (If no, go to item 5.)
Yes
No
4h. Name of former spouse (last name, first name, middle name) 4i. Former spouse’s date of birth (MM/DD/YYYY)

/
4j. Former spouse’s Social Security Number

/

/

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

/

/

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

/

/

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

/

/

/

4n. Do you have another marriage that lasted 10 years or ended in death? (If you need more space to add another former spouse’s name,
date of birth, SSN, marriage start and end dates, or the former spouse’s date of death, add the information in Section 7 Remarks.)
Yes
No

5. TELL US ABOUT YOUR MEDICAL HISTORY:
5a. Have you received regularly scheduled dialysis? (If no, go to item 5e.)

Yes

No

5b. When did dialysis begin? (MM/DD/YYYY)

5c. Has dialysis ended? (If no, go to item 5e.)
Yes
No

5d. When did dialysis end? (MM/DD/YYYY)

5e. Have you participated in (or do you expect to participate in) a
self-dialysis training program? (If no, go to item 5g.)
Yes
No

/
/

/
/

5f. When did you start or when do you plan to start participation in a 5g. Have you received a kidney transplant? (If no, go to item 6)
self-dialysis training program? (MM/DD/YYYY)
Yes
No

/

/

5h. Enter date(s) of transplant(s) (MM/DD/YYYY)

/

/

5i. Were you in the hospital for related procedures the month before
you got the kidney transplant? (If no, go to item 6.)
Yes
No

5j. Enter date(s) of hospitalization (MM/DD/YYYY)

/

/

6. ENROLLMENT IN MEDICARE PART B:
6a. Do you want to sign up for Medicare Part B? (You pay a monthly premium for Part B. If no, go to item 7).

Yes

No

6b. If your application is processed within 5 months after the first month in which you meet the requirements for Medicare, your coverage
will start that first month.
If your application is processed more than 5 months after the first month in which you meet the requirements, you can choose one of the
following for your first month of coverage. (Please check one.)
The earliest possible month (you must pay all premiums for any past months of coverage)
OR
The month this application is filed
OR
The month this application is processed
Get more information about Medicare coverage start and end dates for people with ESRD at medicare.gov/basics/end-stage-renal-disease
NOTE: Medicare offers a benefit that helps you pay for your immunosuppressive drugs beyond 36 months. Visit medicare.gov/basics/endstage-renal-disease for more information.

CMS-43 (xx/xx)

4

7. REMARKS:

8. SIGN YOUR APPLICATION:
8a. If you’re 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.
8b. Written signature (Do not print)

8c. Date signed (MM/DD/YYYY)

/

/

If this application has been signed by mark (X), a witness who knows the person applying must also sign this form.
8d. Name of witness (first and last name)
8e. Signature of witness

8f. Date signed (MM/DD/YYYY)

/

/

I know that anyone who makes a false statement in an application or for use determining a right to payment under the Social Security Act
commits a Federal crime punishable by fine, imprisonment or both. I affirm that all information given in this document is true.

Signature of applicant

Date signed (MM/DD/YYYY)

/

/

How to submit this application
Send your completed and signed application and form CMS-2728 from your provider to
your local Social Security office by fax or mail. Visit www.ssa.gov/locator to get their contact
information.

You must submit evidence to show you have ESRD
You’ll need to submit evidence with your application to show you’ve been diagnosed with EndStage Renal Disease (ESRD). Your provider needs to complete form CMS-2728-End-Stage Renal
Disease Medical Evidence Report Medicare Entitlement and/or Patient Registration. Submit the
completed form with your application. Download the form at cms.gov/Medicare/CMS-Forms/
CMS-Forms/Downloads/CMS2728.pdf.

CMS-43 (xx/xx)

5

PRIVACY ACT STATEMENT: Sections 226A and 1872 of the Social Security Act, as amended, allow SSA to
collect this information. Furnishing this information is voluntary. However, failing to provide all or part
of the information may prevent an accurate and timely decision on any claim filed for medical insurance
and/or hospital insurance.
We will use the information you provide to determine your eligibility for benefits. We may also share
the information for the following purposes, called routine uses:
To Federal, State, or local agencies (or agents on their behalf) for administering income maintenance
or health maintenance programs (including programs under the Social Security Act). Such disclosure
includes, but are not limited to, release of information to: Railroad Retirement Board for administering
provision of the Railroad Retirement Act relating to railroad employment; for administering the
Railroad Unemployment Insurance Act and for administering provisions of the Social Security Act
relating to railroad employment;
Department of Veterans Affairs for administering 38 U.S.C. 1312, and upon request, for determining
eligibility for, or amount of, veterans benefits or verifying other information with respect thereto
pursuant to 38 U.S.C. 5106;
State welfare departments for administering sections 205(c)(2)(B)(i)(II) and 402(a)(25) of the Social
Security Act requiring information about assigned Social Security numbers for Temporary Assistance for
Needy Families (TANF) program purposes and for determining a recipient’s eligibility under the TANF
program; and
State agencies for administering the Medicaid program.
To contractors and other Federal agencies, as necessary, for the purpose of assisting the Social Security
Administration (SSA) in the efficient administration of its programs. We will disclose information under
the routine use only in situations in which SSA may enter into a contractual or similar agreement with a
third party to assist in accomplishing an agency function relating to this system of records.
In addition, we may share this information in accordance with the Privacy Act and other Federal laws.
For example, where 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 repayment of incorrect or delinquent debts under these
programs.
A list of additional routine uses is available in our Privacy Act System of Records Notice (SORN) 60-0090,
entitled Master Beneficiary Record, as published in the Federal Register (FR) on January 11, 2006, at 71
FR 1826. Additional information, and a full listing of all of our SORNs, is available on our website at
www.ssa.gov/privacy.
CMS will maintain records received during eligibility determinations from SSA in a CMS System of
Records, the Medicare Beneficiary Database (MBD) SORN 09-70-0536 as published in the Federal Register
(FR) on February 14, 2018, at 71 FR 11420. Additional information on CMS SORNs and permissible
Routine Uses for disclosure can be located at our Privacy website https://www.hhs.gov/foia/privacy/
sorns/index.html.

PRA DISCLOSURE STATEMENT: 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 0938-0080. The time required to complete this information collection is estimated to average 10 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 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.
Please do not send applications, claims, payments, medical records or any documents containing sensitive information to
the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden
approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you
have questions or concerns regarding where to submit your documents, please contact the Social Security Administration at
1-800-772-1213. TTY users can call 1-800-325-0778.
CMS-43 (xx/xx)

6