Crosswalk

Revisions to Form CMS 40B (OMB 0938-1230) Application for Enrollment in Medicare Part B (Medical Insurance)
The form was updated to add the optional collection of email addresses. In response to SSA technician’s feedback, the form now
includes a question that allows the applicant to select a Medicare start date. CMS’ Office of Communications provided feedback on
the form design and the layout of the questions. The form was redesigned to give the applicant’s a more user-friendly experience. No
additional changes were made and the burden was not impacted by the changes.
Changes
Updated Form

Original Form

Reason for Change

Title: Request for
Enrollment in Medicare
Part B (Medical
Insurance)
Instructions page

Title: Application for
Enrollment in Medicare
Part B (Medical
Insurance)
Instructions page

OC plain language suggestion.

Burden
Effect
N/A

Updated to plain language.

N/A

Section 1: Basic
Information
• New, optional,
email address
collection
Section 2: Enrollment in
Medicare Part B
• New question
related to the
applicant
choosing their
Medicare
coverage start
date.
Section 3: Signature(s)

Questions numbered
without having a
specific section or
category.

•
•
•

•
•

Updated formatting to
match Medicare brand &
style
Updated language to
align with Medicare.gov
program info
Linked to Medicare.gov
for program details so
info is current &
comprehensive
Added SHIPs resource
language to the “Get
help” section
Removed field numbers
unless used for

N/A

Removal of Step-byStep Instructions

•
•
•

navigation (i.e. “go to
item 4”)
Standardized field labels
across forms
Standardized the
“witness” section across
forms
Per the Office of
Communications
suggestion, step-by-step
instructions aren’t
needed on enrollment
forms, as they don’t add
additional information