Article Structure
The CMS-40B form is an essential document for individuals seeking to enroll in Medicare, specifically for those who qualify for Part B coverage. This form plays a crucial role in the enrollment process, allowing eligible beneficiaries to access a range of healthcare services. Completing the CMS-40B form accurately is vital, as it ensures that applicants receive the benefits they are entitled to without unnecessary delays. The form requires personal information, including the applicant's name, address, and Social Security number, as well as details about their eligibility status. Additionally, applicants must indicate their reasons for enrollment, whether they are new beneficiaries or those re-enrolling after a period of non-coverage. Understanding the nuances of this form can greatly simplify the enrollment experience and help individuals make informed decisions about their healthcare options.
Form Sample
CMS-40B (07/2025)
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.
1
CMS-40B (07/2025)
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
ZIP code
4. Phone number 5. Email address
U.S. Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form Approved
OMB No. 0938-1230
Expires: 07/31/2028
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.) .................................................................................
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 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.
Start date:
End date:
Not ended
Dates of health coverage from employer (or non-profit organization)
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)
2
CMS-40B (07/2025)
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.
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 Ocer, 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 Oce. 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.
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 Aairs 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
ecient 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.
Document Specifications
| Fact Name | Details |
|---|---|
| Purpose | The CMS-40B form is used to apply for Medicare Part B coverage. |
| Eligibility | Individuals who are 65 or older, or those under 65 with certain disabilities, can use this form. |
| Filing Period | Applications can be submitted during the initial enrollment period, which lasts seven months. |
| Governing Law | This form is governed by federal Medicare laws and regulations. |
Steps to Filling Out CMS-40B
Completing the CMS-40B form is an essential step in the process of obtaining Medicare coverage. After filling out the form, you will need to submit it to the appropriate Medicare office for processing. This ensures that your application is reviewed and that you can receive the benefits you are seeking.
- Begin by downloading the CMS-40B form from the official Medicare website or obtain a physical copy from your local Medicare office.
- Carefully read the instructions provided with the form to understand the requirements and sections that need to be completed.
- Fill in your personal information at the top of the form, including your name, address, date of birth, and Medicare number if applicable.
- Provide information regarding your eligibility for Medicare, including details about any current or previous health insurance coverage.
- Complete the section regarding your current situation, such as whether you are applying for the first time or making changes to your existing coverage.
- Review the form for accuracy and ensure that all required fields are filled out completely.
- Sign and date the form at the designated area 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 to the appropriate Medicare office either by mail or through an online portal, if available.
More About CMS-40B
What is the CMS-40B form?
The CMS-40B form is used for individuals who wish to apply for or change their Medicare coverage. Specifically, it is the application for the Medicare Part B program, which helps cover outpatient care, preventive services, and some home health services. Completing this form is an essential step for those seeking to enroll in Medicare or modify their existing coverage.
Who should fill out the CMS-40B form?
This form is primarily for individuals who are eligible for Medicare and want to enroll in Part B. 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). If you are already enrolled in Medicare Part A and wish to add Part B, this form is necessary.
How can I obtain the CMS-40B form?
The CMS-40B form can be downloaded directly from the official Medicare website. Alternatively, you can request a physical copy by calling Medicare’s customer service. They can mail the form to your address. It’s important to ensure you have the most current version of the form, as updates may occur periodically.
What information do I need to provide on the CMS-40B form?
When filling out the CMS-40B form, you will need to provide personal information such as your name, address, Social Security number, and date of birth. Additionally, you may need to include details about your current health insurance coverage, if applicable. Be sure to have this information readily available to ensure the process goes smoothly.
How do I submit the CMS-40B form?
You can submit the completed CMS-40B form in several ways. One option is to mail it to your local Social Security office. Alternatively, if you are applying online, you can submit it through the Medicare website. Make sure to check the submission guidelines to avoid any delays in processing your application.
Is there a deadline for submitting the CMS-40B form?
Yes, there are specific deadlines depending on your circumstances. Generally, if you are turning 65, you should apply for Medicare during your Initial Enrollment Period, which begins three months before your birthday month and ends three months after. If you miss this window, you may have to wait for the General Enrollment Period, which runs from January 1 to March 31 each year.
What happens after I submit the CMS-40B form?
After submitting your CMS-40B form, the Social Security Administration will review your application. You should receive a confirmation or decision regarding your enrollment in Medicare Part B. This process may take several weeks, so it’s advisable to keep a copy of your submitted form and any correspondence for your records.
Can I cancel my Medicare Part B coverage after enrolling?
Yes, it is possible to cancel your Medicare Part B coverage. However, this can only be done during specific periods, such as the General Enrollment Period or a Special Enrollment Period if you qualify. Keep in mind that canceling Part B may result in a penalty if you decide to re-enroll later, so consider your options carefully.
Where can I find additional help with the CMS-40B form?
If you need assistance with the CMS-40B form, there are several resources available. You can contact Medicare directly via their customer service hotline. Additionally, local State Health Insurance Assistance Programs (SHIP) offer free counseling and can help guide you through the application process. Online forums and community organizations may also provide helpful information.
Common mistakes
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Failing to provide accurate personal information. It is crucial to ensure that your name, address, and Social Security number are correct. Any discrepancies can lead to delays in processing.
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Not signing the form. Many individuals forget to sign the CMS-40B form. Without a signature, the form is considered incomplete and cannot be processed.
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Omitting required documentation. Applicants often neglect to include necessary documents, such as proof of income or residency. This omission can result in rejection of the application.
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Submitting the form to the wrong address. It is essential to verify the correct mailing address for submission. Sending the form to an incorrect location can cause significant delays.
Documents used along the form
The CMS-40B form is essential for individuals applying for Medicare Part B. However, there are several other documents that may be required or helpful in conjunction with this form. Below is a list of commonly used forms and documents that can assist applicants in the process.
- CMS-40A Form: This form is used to apply for Medicare Part A. It is often submitted alongside the CMS-40B to ensure that individuals receive both hospital and medical insurance coverage.
- CMS-L564 Form: This document serves as proof of employment or group health coverage. It is particularly important for those who are eligible for Medicare but have had health insurance through an employer.
- Social Security Card: A copy of the Social Security card is frequently required to verify identity and eligibility for Medicare benefits. It helps streamline the application process.
- Proof of Residency: Documents such as utility bills or lease agreements may be needed to confirm the applicant's current address. This is important for determining eligibility based on state residency.
Having these forms and documents ready can significantly simplify the application process for Medicare Part B. Ensuring that all necessary information is included can help avoid delays and ensure timely access to benefits.
Similar forms
The CMS-40B form is often compared to the Medicare Part B Enrollment Application, also known as the CMS-40. Like the CMS-40B, this document is essential for individuals looking to enroll in Medicare Part B. It serves as a formal request to receive medical insurance coverage under Medicare. The similarities extend beyond their purpose; both forms require personal information, including Social Security numbers and addresses, to ensure accurate processing. Additionally, both forms can be submitted online or via mail, offering flexibility to applicants.
Another document that shares similarities with the CMS-40B is the Medicare Advantage Plan Enrollment Form. This form is used by individuals who wish to enroll in a Medicare Advantage plan, which is an alternative way to receive Medicare benefits. Both the CMS-40B and the Medicare Advantage Plan Enrollment Form require applicants to provide detailed personal information and health coverage preferences. They also both have specific deadlines for enrollment, emphasizing the importance of timely submission to avoid gaps in coverage.
The Medicaid Application form is yet another document that resembles the CMS-40B. While Medicaid is a different program focused on low-income individuals, the application process shares a common goal: securing health coverage. Both forms require extensive personal and financial information to determine eligibility. They also necessitate proof of income and residency, making them critical documents for those seeking assistance in managing healthcare costs.
Lastly, the Social Security Administration's Application for a Social Security Card (Form SS-5) is similar in that it requires personal identification details. While this form is not directly related to health coverage, it is often a prerequisite for completing other applications, including the CMS-40B. Both forms demand accurate information to prevent delays in processing. Additionally, the urgency of submitting these documents on time cannot be overstated, as they are crucial for accessing essential services.
Dos and Don'ts
When filling out the CMS-40B form, it is essential to follow certain guidelines to ensure accuracy and completeness. Here are four important do's and don'ts:
- Do double-check all personal information for accuracy.
- Do read the instructions carefully before starting the form.
- Don't leave any required fields blank.
- Don't submit the form without reviewing it for errors.
Misconceptions
The CMS-40B form is an important document for individuals seeking to enroll in Medicare. However, several misconceptions often surround it. Here are six common misunderstandings:
- It's only for new Medicare applicants. Many believe the CMS-40B is exclusively for those enrolling for the first time. In reality, it can also be used for individuals who want to switch plans or make changes to their existing coverage.
- You can submit it at any time. Some think they can send in the CMS-40B whenever they choose. However, there are specific enrollment periods when the form must be submitted to ensure coverage starts on time.
- It’s a complicated form. Many people feel intimidated by the CMS-40B, assuming it’s filled with complex legal language. In truth, the form is designed to be straightforward and user-friendly.
- Only seniors need to fill it out. While seniors are the primary users, younger individuals who qualify for Medicare due to disabilities also need to complete the CMS-40B.
- Submitting the form guarantees coverage. Some assume that simply sending in the CMS-40B ensures they will be enrolled in Medicare. Approval is contingent on meeting eligibility criteria, so it’s essential to understand those requirements.
- You can only use it for Original Medicare. A common belief is that the CMS-40B is limited to Original Medicare enrollment. However, it can also be used for Medicare Advantage plans and certain other options.
Understanding these misconceptions can help individuals navigate the Medicare enrollment process more effectively.
Key takeaways
When filling out and using the CMS-40B form, there are several important points to keep in mind. This form is crucial for individuals seeking to apply for or change their Medicare coverage. Here are some key takeaways:
- Understand the Purpose: The CMS-40B form is primarily used for applying for Medicare Part B. Knowing its purpose helps ensure that you fill it out correctly.
- Gather Required Information: Before starting the form, collect necessary personal information such as your Social Security number, date of birth, and any previous Medicare information.
- Be Accurate: Accuracy is vital. Double-check all entries to avoid delays in processing your application.
- Submit on Time: Pay attention to deadlines. Submitting your form within the designated enrollment period is essential to avoid penalties.
- Keep Copies: After submitting the form, retain a copy for your records. This can be helpful if any issues arise later.
- Follow Up: After submission, monitor the status of your application. If you do not receive confirmation, reach out to Medicare for clarification.
By keeping these takeaways in mind, you can navigate the process of filling out the CMS-40B form with confidence and ease.