The CMS-40B form is an application used to enroll in Medicare Part B, which provides essential medical coverage for eligible individuals. Completing this form is a crucial step for those who want to access necessary healthcare services. To get started on your Medicare enrollment, fill out the form by clicking the button below.
The CMS-40B form plays a crucial role in the Medicare system, serving as a key document for individuals seeking to enroll in or change their Medicare coverage. This form is primarily used by people who are eligible for Medicare and wish to apply for Part B, which covers essential medical services, including doctor visits and outpatient care. Understanding the CMS-40B is vital for anyone navigating the complexities of Medicare enrollment. It requires personal information, such as name, address, and Social Security number, along with details about prior health coverage. Additionally, the form helps determine eligibility based on specific criteria, such as age or disability status. Completing the CMS-40B accurately is important, as it can influence the timing and cost of coverage. With this form, individuals can ensure they receive the necessary healthcare services when they need them most, making it a significant step in managing their health and wellness.
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 1–March 31 each year
•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.
Visit Medicare.gov/basics/get-started-with-medicare to learn more about when you can sign up for Medicare, when your coverage can start, and special situations for people under 65 with a disability.
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 1-800-772-1213. TTY users call 1-800-325-0778.
•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.
•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 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-40B (07/2025)
U.S. Department of Health and Human Services
Form Approved
OMB No. 0938-1230
Centers for Medicare & Medicaid Services
Expires: 07/31/2028
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
ZIP code
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
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 non-profit organization that
provided health coverage to you? (If yes, complete item 3.)
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 CMS-L564 (Request for Employment Information) and return it with your application.
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.
Dates of health coverage from employer (or non-profit organization)
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.)
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)
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) 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 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 HHS.gov/foia/privacy/sorns/index.html.
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 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. Important: Do not send this form or any items with your personal information (such as claims, payments, medical records, etc.) to the PRA Reports Clearance Office. Any items we get that aren’t about how to improve this form or its collection burden (outlined in OMB 0939-0251) will be destroyed. It will not be kept, reviewed, or forwarded to Social Security or any other agency.
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Filling out the CMS-40B form is an important step for those who need to apply for assistance. After completing the form, you will need to submit it to the appropriate agency. Make sure to keep a copy for your records.
What is the CMS-40B form?
The CMS-40B form is a document used by individuals applying for Medicare Part B. It serves as an application for those who wish to enroll in this part of Medicare, which primarily covers outpatient care, preventive services, and certain medical supplies. By completing this form, applicants provide essential information that helps the Centers for Medicare & Medicaid Services (CMS) determine their eligibility for coverage.
Who is eligible to fill out the CMS-40B form?
Eligibility to complete the CMS-40B form generally includes individuals who are 65 years of age or older, as well as younger individuals with certain disabilities or specific medical conditions, such as End-Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS). It is important to note that individuals who are already enrolled in Medicare Part A do not need to fill out this form to obtain Part B coverage.
How can I obtain the CMS-40B form?
The CMS-40B form can be easily accessed online through the official Medicare website. Alternatively, individuals may request a paper copy by contacting their local Social Security office. It is also possible to find the form at various community centers or organizations that assist with Medicare enrollment.
What information do I need to provide on the CMS-40B form?
When completing the CMS-40B form, applicants must provide personal information, including their name, address, date of birth, and Social Security number. Additionally, details regarding current health insurance coverage, if any, must be disclosed. This information helps ensure that the application is processed accurately and efficiently.
What happens after I submit the CMS-40B form?
Once the CMS-40B form is submitted, the Centers for Medicare & Medicaid Services will review the application. Applicants can expect to receive a confirmation of their enrollment status within a few weeks. If there are any issues or additional information is needed, CMS will reach out directly to the applicant. It is advisable to keep a copy of the submitted form for personal records.
Can I make changes to my application after submitting the CMS-40B form?
Yes, individuals can make changes to their application after submission. If there are updates to personal information or changes in health insurance status, it is essential to contact the Social Security Administration or the local Medicare office as soon as possible. This ensures that the information on file remains accurate and up-to-date, which is crucial for maintaining proper Medicare coverage.
Filling out the CMS-40B form can be a straightforward process, but many individuals make common mistakes that can lead to delays or complications in their applications. One frequent error is providing inaccurate personal information. This can include misspellings of names, incorrect Social Security numbers, or wrong addresses. Such inaccuracies can result in the application being rejected or delayed, as the information needs to match official records.
Another mistake often seen is the failure to sign and date the form. Many people may complete the form but overlook the importance of signing it. Without a signature, the application is considered incomplete. Additionally, not dating the form can create confusion about when the application was submitted, which may affect processing times.
Individuals also sometimes neglect to include necessary supporting documents. The CMS-40B form may require additional information, such as proof of income or residency. Failing to provide these documents can lead to a denial of benefits or a request for further information, which can prolong the process. It is essential to review the requirements carefully before submission.
Lastly, some applicants do not take the time to read the instructions thoroughly. Each section of the CMS-40B form has specific guidelines that must be followed. Misunderstanding these instructions can result in errors that could have been easily avoided. Taking a moment to ensure that every part of the form is completed correctly can save time and effort in the long run.
The CMS-40B form is an important document used in the Medicare program, specifically for individuals who want to apply for Medicare Part B. Alongside this form, there are several other documents that may be required to ensure a smooth application process. Below is a list of commonly used forms and documents that often accompany the CMS-40B.
Having these documents ready can make the application process more efficient. It’s important to ensure that all forms are completed accurately to avoid delays. If you have any questions about these documents, consider reaching out to a Medicare representative for assistance.
The CMS-40B form is an important document related to Medicare, specifically for those looking to apply for or change their Medicare Part B coverage. Several other forms serve similar purposes in the realm of health insurance and Medicare applications. Below is a list of five documents that share similarities with the CMS-40B form:
Each of these documents plays a vital role in the Medicare system, ensuring that individuals can access the health care services they need. Understanding the similarities can help streamline the process of managing Medicare coverage effectively.
When filling out the CMS-40B form, it’s essential to follow specific guidelines to ensure your application is processed smoothly. Here’s a list of things you should and shouldn’t do.
Taking these steps can help you avoid delays and ensure your application is processed in a timely manner.
The CMS-40B form is an important document for those looking to apply for Medicare coverage. However, there are several misconceptions surrounding it that can lead to confusion. Here are five common misunderstandings:
Understanding these misconceptions can help you navigate the Medicare application process more effectively. Being informed allows you to make better decisions regarding your healthcare coverage.
The CMS-40B form is an important document for individuals seeking to apply for or change their Medicare coverage. Here are some key takeaways to consider when filling out and using this form:
Using the CMS-40B form correctly can help ensure you receive the benefits you need under Medicare Part B.