Article Guide
The CMS-40B form plays a crucial role in the Medicare system, specifically for individuals seeking to apply for or change their Medicare coverage. This form is designed for people who are eligible for Medicare but need assistance with enrollment, particularly those who qualify for premium-free Part A or want to enroll in Part B. Completing the CMS-40B form accurately is essential, as it helps ensure that beneficiaries receive the healthcare services they need without unnecessary delays. The form requires personal information, including Social Security numbers and details about previous health coverage. Understanding the implications of this form can significantly impact one’s access to medical services and financial responsibilities. Timely submission of the CMS-40B is vital, as it affects when coverage begins and can influence overall healthcare costs. Navigating the Medicare enrollment process can be daunting, but familiarity with the CMS-40B form is a key step toward securing the necessary benefits.
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Request for Enrollment in Medicare Part B (Medical Insurance)
Use this form if you already have Medicare Part A and want to sign up for Part B (Medical Insurance). You can use this form to sign up for Part B during these times:
•During your Initial Enrollment Period
•During the General Enrollment Period from January
•If you’re eligible for a Special Enrollment Period
If you don’t have Part A, don’t complete this application. Contact Social Security to apply for Medicare for the first time.
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Submit your form by mail or fax
Mail or fax your completed, signed form to your local Social Security office. Find an office near you at SSA.gov/locator.
Get help with this form
•Phone: Call Social Security at
•En Español: Llame a SSA gratis al
•For an office near you visit SSA.gov/locator.
•State Health Insurance Assistance Program (SHIP): Visit shiphelp.org to get free, personalized, and unbiased health insurance counseling from your local SHIP.
Get information in another format
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
U.S. Department of Health and Human Services |
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Centers for Medicare & Medicaid Services |
Expires: 07/31/2028 |
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Request for Enrollment in Medicare Part B (Medical Insurance)
Section 1: Basic information
1. Medicare Number
2. First name |
Middle name |
Last name |
Suffix |
3. Mailing address (number and street, P.O. Box, or route)
City |
State |
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ZIP code |
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4. Phone number
5. Email address
Section 2: Enrollment in Medicare Part B
1. Do you have (or did you have) coverage through an employer or union group health plan |
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since you turned 65? (If yes, complete item 3.) |
Yes No |
Note: If you sign up for Part B, you must pay premiums for every month you have the coverage.
2. Are you currently (or were you) an international volunteer for a |
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provided health coverage to you? (If yes, complete item 3.) |
Yes No |
3.Enter dates of employment (or volunteer work) and health coverage (enter dates as mm/yyyy). Attach a separate sheet if you need more space. Have your employer fill out the form
Dates you (or your spouse) worked for an employer that provided health coverage
Start date:
End date:
Not ended
Dates you worked as a volunteer outside the U.S.
Start date:
End date:
Not ended
Dates of health coverage from employer (or
Start date:
End date:
Not ended
4.Has an employer, health insurance provider, or other entity asked or required you to enroll in Part B? (If yes, explain how and why in the space below, and include proof or documentation
with this form.) |
Yes No |
Choose your coverage start date
If you’re enrolling in Medicare while you’re still covered by a group health plan based on current employment (or during the first full month you’re not enrolled in the group health plan), you can choose when your Medicare coverage will start. Choose one:
The first day of the month you enroll
The first day of any of the 3 months after you enroll. Write the month and year you want coverage to start: (mm/yyyy)
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Section 3: Signature(s)
1. Signature of applicant
2. Date signed (mm/dd/yyyy)
If this form has been signed by mark (X), a witness who knows the person applying must also sign below:
3. Name of witness (first and last name)
4. Signature of witness
5. Date signed (mm/dd/yyyy)
Submit your form by mail or fax
Mail or fax your completed, signed form to your local Social Security office. Find an office near you at SSA.gov/locator.
Privacy Act Statement: Sections 1837, 1838 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: 1) 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; 2) 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; 3) 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 4) 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)
CMS will maintain records received during eligibility determinations from SSA in a CMS System of Records, the Medicare Beneficiary Database (MBD) SORN
Paperwork Reduction Act: 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
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Form Specifications
| Fact Name | Details |
|---|---|
| Purpose | The CMS-40B form is used to apply for Medicare Part B, which covers outpatient medical services. |
| Eligibility | Individuals aged 65 or older, or those under 65 with certain disabilities, can apply using this form. |
| Submission Method | The form can be submitted online, by mail, or in person at a local Social Security office. |
| Governing Law | This form is governed by federal regulations under the Social Security Act, Title XVIII. |
| Filing Deadline | Applications should be submitted during the designated enrollment periods to avoid late enrollment penalties. |
| Required Information | Applicants must provide personal information, including Social Security number, address, and health coverage details. |
CMS-40B: Usage Guidelines
The CMS-40B form is essential for individuals looking to apply for Medicare. After completing the form, you will submit it to the appropriate Medicare office. This submission will initiate the process of reviewing your application and determining your eligibility.
- Begin by downloading the CMS-40B form from the official Medicare website or obtain a physical copy from a local Medicare office.
- Carefully read the instructions provided with the form to understand the information required.
- Fill in your personal information at the top of the form. This includes your name, address, date of birth, and Social Security number.
- Provide information about your Medicare eligibility, including any previous enrollment details.
- Indicate your preferred method of communication by checking the appropriate box.
- Complete any additional sections as required, such as information about your spouse or dependents, if applicable.
- Review the entire form for accuracy and completeness. Make sure all required fields are filled out.
- Sign and date the form at the bottom to certify that the information provided is true and complete.
- Make a copy of the completed form for your records before submitting it.
- Submit the form by mail or in person to the designated Medicare office, as indicated in the instructions.
Your Questions, Answered
What is the CMS-40B form?
The CMS-40B form is used by individuals to apply for Medicare Part B. This form is essential for those who wish to enroll in Medicare Part B, which covers outpatient care, preventive services, and some home health services. Completing this form accurately is crucial to ensure timely enrollment and access to necessary medical services.
Who should use the CMS-40B form?
This form is intended for individuals who are eligible for Medicare and wish to enroll in Part B. Typically, this includes people who are turning 65, those who are under 65 with certain disabilities, and individuals with End-Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS).
How can I obtain the CMS-40B form?
You can download the CMS-40B form directly from the official Medicare website. Alternatively, you can request a paper form by contacting the Social Security Administration or visiting your local Social Security office.
When should I submit the CMS-40B form?
It is advisable to submit the CMS-40B form during your initial enrollment period, which begins three months before you turn 65 and ends three months after your birthday month. If you miss this window, you may face penalties or delays in coverage.
What information do I need to provide on the CMS-40B form?
The form requires personal information, including your name, address, date of birth, and Social Security number. You will also need to indicate whether you are currently receiving benefits from Social Security or Railroad Retirement, and if you have any other health insurance coverage.
Can I submit the CMS-40B form online?
Yes, if you are already receiving Social Security benefits, you may be able to enroll in Medicare Part B online through the Social Security Administration’s website. However, if you are not receiving benefits, you will need to submit a paper form by mail or in person.
What happens after I submit the CMS-40B form?
Once you submit the CMS-40B form, the Social Security Administration will process your application. You will receive a confirmation and information regarding your enrollment status. If additional information is needed, they will reach out to you directly.
What should I do if my application is denied?
If your application for Medicare Part B is denied, you will receive a notice explaining the reason for the denial. You have the right to appeal the decision. Instructions for the appeals process will be included in the notice you receive.
Is there a fee associated with the CMS-40B form?
There is no fee to submit the CMS-40B form or to enroll in Medicare Part B. However, there may be monthly premiums associated with Medicare Part B coverage, which vary based on your income and other factors.
Can I change my Medicare Part B coverage after enrolling?
Yes, you can change your Medicare Part B coverage during the annual Open Enrollment Period, which runs from October 15 to December 7 each year. Additionally, you may qualify for a Special Enrollment Period under certain circumstances, such as losing other health coverage.
Common mistakes
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Incorrect Personal Information: People often make mistakes when entering their name, address, or date of birth. Double-checking these details can prevent delays.
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Missing Signatures: Failing to sign the form is a common oversight. Ensure that all required signatures are included before submission.
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Not Providing Supporting Documents: Some applicants forget to attach necessary documents, such as proof of income or residency. These documents are crucial for processing.
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Incorrectly Reporting Income: Many individuals either overstate or understate their income. Accurate reporting is essential to determine eligibility.
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Ignoring Instructions: Skipping over the instructions can lead to filling out the form incorrectly. It's important to read all guidelines carefully to avoid errors.
Documents used along the form
The CMS-40B form is essential for individuals seeking to enroll in Medicare Part B. However, several other forms and documents often accompany it to ensure a smooth application process. Below are five commonly used forms and documents that you may encounter alongside the CMS-40B.
- CMS-40A Form: This form is used to apply for Medicare Part A. It is typically filled out by individuals who are eligible for hospital insurance based on their work history or the work history of a spouse.
- CMS-L564 Form: The Request for Employment Information form is necessary for those who are applying for Medicare and need to provide proof of employment. This document helps verify eligibility based on current or past employment.
- Medicare Enrollment Application: This application is a comprehensive document that details your personal information, including your Medicare number, and is used for various enrollment types, including Part C and D.
- Proof of Citizenship or Legal Residency: Documentation such as a birth certificate or a green card may be required to establish your eligibility for Medicare. This proof is critical for confirming your identity and residency status.
- Social Security Card: Your Social Security number is necessary for Medicare enrollment. Having your Social Security card on hand can expedite the application process and ensure accuracy in your application.
Understanding these documents and their purposes can significantly streamline your Medicare enrollment experience. Being prepared with the necessary paperwork will help facilitate a smoother process and reduce potential delays.
Similar forms
The CMS-40B form is a crucial document used in the Medicare program, specifically for individuals who wish to apply for or change their Medicare Part B coverage. Several other documents share similarities with the CMS-40B form in terms of purpose, structure, or function. Below are six such documents:
- CMS-40A Form: This form is used for Medicare beneficiaries who want to apply for Medicare Part A coverage. Like the CMS-40B, it requires personal information and details about eligibility.
- CMS-855I Form: This document is utilized by healthcare providers to enroll in Medicare. It also requires comprehensive information about the provider, similar to the personal details required in the CMS-40B.
- CMS-10114 Form: This is the application for Medicare Part D, which provides prescription drug coverage. It shares the same goal of ensuring beneficiaries have the necessary coverage while requiring personal and eligibility information.
- CMS-1763 Form: This form is used to request a waiver of premium for Medicare Part B. It parallels the CMS-40B in that it involves requests for changes in coverage and requires specific personal information.
- CMS-10182 Form: This document is the request for a Medicare Savings Program. It is similar in that it helps individuals access benefits while requiring detailed personal and financial information.
- CMS-1490S Form: This is the application for Extra Help with Medicare prescription drug costs. Like the CMS-40B, it is focused on eligibility and requires a variety of personal details to assess qualification.
Dos and Don'ts
When filling out the CMS-40B form, it’s important to pay attention to the details. This form is essential for applying for Medicare coverage, and getting it right can make a significant difference in your healthcare journey. Here are some dos and don'ts to keep in mind:
- Do read the instructions carefully before you start filling out the form.
- Don't leave any sections blank. If a question does not apply to you, write "N/A."
- Do use black or blue ink to ensure that your answers are legible.
- Don't rush through the form. Take your time to avoid mistakes.
- Do double-check your personal information for accuracy, including your name and address.
- Don't forget to sign and date the form at the bottom before submitting it.
- Do keep a copy of the completed form for your records.
- Don't send the form without reviewing it for any errors or omissions.
- Do reach out for assistance if you have questions about any part of the form.
By following these guidelines, you can help ensure that your application process goes smoothly. Taking the time to fill out the CMS-40B form correctly can lead to a more efficient experience with Medicare.
Misconceptions
The CMS-40B form, also known as the "Application for Enrollment in Medicare Part B," is an essential document for those looking to enroll in Medicare. However, several misconceptions surround this form. Here are six common misunderstandings:
- Myth 1: The CMS-40B form is only for seniors.
- Myth 2: Submitting the CMS-40B form guarantees immediate coverage.
- Myth 3: You can submit the CMS-40B form at any time.
- Myth 4: The CMS-40B form is complicated and difficult to complete.
- Myth 5: You must have a specific reason to apply using the CMS-40B form.
- Myth 6: The CMS-40B form can be submitted online only.
Many believe that only individuals over 65 can use the CMS-40B form. In reality, younger individuals with certain disabilities or health conditions may also be eligible for Medicare and can complete this form.
Some applicants think that once they submit the CMS-40B form, they will receive immediate Medicare coverage. However, there are specific enrollment periods, and coverage typically begins only after processing the application.
Many people assume that they can apply for Medicare whenever they wish. However, there are designated enrollment periods, and missing these windows may result in delayed coverage or penalties.
While some may find the form intimidating, it is designed to be straightforward. With clear instructions and a focus on essential information, most individuals can complete it without much difficulty.
Some believe they need a specific reason to enroll in Medicare Part B. In fact, anyone who meets the eligibility criteria can apply, regardless of their current health status or circumstances.
While online submission is an option, applicants can also mail the completed form or submit it in person at their local Social Security office, providing flexibility in how they choose to apply.
Understanding these misconceptions can help individuals navigate the Medicare enrollment process more effectively. Being informed empowers applicants to make the best decisions regarding their healthcare coverage.
Key takeaways
When it comes to the CMS-40B form, understanding its purpose and how to fill it out correctly is crucial for accessing Medicare benefits. Here are some key takeaways to keep in mind:
- Purpose of the Form: The CMS-40B form is used to apply for Medicare Part B, which covers outpatient medical services. Completing this form is essential for those who are eligible and wish to enroll.
- Eligibility Requirements: To fill out the CMS-40B, you must meet specific eligibility criteria, including age and residency requirements. Make sure to review these before starting your application.
- Timely Submission: It's important to submit the CMS-40B form within the designated enrollment periods. Missing these deadlines can result in delayed coverage and potential penalties.
- Accurate Information: Ensure that all information provided on the form is accurate and complete. Inaccuracies can lead to processing delays or complications in your enrollment.