Contents
The CMS-40B form plays a crucial role in the Medicare enrollment process, particularly for individuals seeking to apply for or change their Medicare coverage. This form is essential for those who qualify for Medicare benefits and wish to enroll in a Medicare Advantage plan or change their existing plan. It serves as a formal request to the Centers for Medicare & Medicaid Services (CMS) to facilitate the enrollment process. 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 also captures important personal information, including the applicant's name, address, and Medicare number, which helps streamline the processing of applications. Understanding the requirements and steps involved in filling out this form can significantly ease the enrollment experience for individuals navigating the complexities of Medicare. By ensuring that all necessary information is provided, applicants can avoid potential issues that may arise during the review process.
Preview - CMS-40B Form
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 Specifics
| Fact Name | Description |
|---|---|
| Purpose | The CMS-40B form is used to apply for Medicare Part B coverage. |
| Eligibility | Individuals aged 65 and older, as well as certain younger individuals with disabilities, can use this form. |
| Filing Period | Applications can be submitted during the initial enrollment period, general enrollment period, or special enrollment period. |
| State-Specific Forms | Some states may have additional requirements or forms. Check with local Medicare offices. |
| Governing Laws | The CMS-40B is governed by federal Medicare laws and regulations. |
| Submission Method | The form can be submitted online, by mail, or in person at local Social Security offices. |
| Processing Time | Processing typically takes a few weeks, but it may vary based on the volume of applications. |
| Required Information | Applicants must provide personal information, including name, address, and Social Security number. |
| Assistance | Help is available through the Social Security Administration for those who need guidance in completing the form. |
CMS-40B: Usage Instruction
Filling out the CMS-40B form is an important step in the process that follows. Once you have the form completed, it will be submitted for processing, and you’ll be able to move forward with your application. Here are the steps to help you fill out the form accurately.
- Begin by downloading the CMS-40B form from the official website or obtain a physical copy.
- Read through the instructions provided with the form to understand what information is required.
- In the first section, enter your personal information, including your full name, address, and date of birth.
- Provide your Social Security number in the designated area. Ensure that this is accurate to avoid delays.
- Fill in your contact information, including your phone number and email address, if applicable.
- Indicate your Medicare number if you have one, or check the box if you do not.
- Complete the section regarding your eligibility and the type of coverage you are applying for.
- If applicable, provide information about any other health insurance coverage you may have.
- Review all the information you have entered for accuracy and completeness.
- Sign and date the form in the designated area to confirm that the information is correct.
- Make a copy of the completed form for your records before submission.
- Submit the form according to the instructions provided, either by mail or online, as applicable.
Learn More on CMS-40B
What is the CMS-40B form?
The CMS-40B form is used to apply for Medicare Part B. This form is essential for individuals who wish to enroll in Medicare Part B, which covers medical services such as doctor visits and outpatient care. It serves as an official request to initiate coverage under this part of Medicare.
Who should fill out the CMS-40B form?
Individuals who are eligible for Medicare and wish to enroll in Part B should complete the CMS-40B form. This includes:
- People turning 65 years old.
- Individuals under 65 who qualify due to disability.
- Those who are eligible due to certain medical conditions.
How do I obtain the CMS-40B form?
The CMS-40B form can be obtained from multiple sources:
- The official Medicare website.
- Local Social Security Administration offices.
- By calling Medicare customer service.
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. Late enrollment may lead to penalties, so timely submission is crucial.
What information is required on the CMS-40B form?
The form requires various personal details, including:
- Your name and contact information.
- Your Social Security number.
- Your date of birth.
- Information regarding your current health insurance coverage.
Can I submit the CMS-40B form online?
Currently, the CMS-40B form cannot be submitted online. Applicants must print the completed form and mail it to their local Social Security office. Ensure that you send it to the correct address to avoid delays in processing.
What happens after I submit the CMS-40B form?
After submission, the Social Security Administration will process your application. You will receive a confirmation once your enrollment is approved. If there are any issues or additional information needed, they will contact you directly.
Is there a fee associated with the CMS-40B form?
There is no fee to submit the CMS-40B form. However, there may be premiums associated with Medicare Part B coverage, which you will need to pay once your enrollment is confirmed.
What if I miss the enrollment period for the CMS-40B form?
If you miss your Initial Enrollment Period, you may still enroll during the General Enrollment Period, which runs from January 1 to March 31 each year. However, late enrollment may result in a penalty added to your monthly premium.
Where can I get help if I have questions about the CMS-40B form?
If you have questions or need assistance with the CMS-40B form, you can contact:
- Your local Social Security office.
- The Medicare customer service hotline.
- Medicare counselors or local advocacy groups specializing in Medicare assistance.
Common mistakes
Filling out the CMS-40B form can be a daunting task for many individuals. One common mistake is providing incorrect personal information. This includes errors in names, addresses, or Social Security numbers. Even a small typo can lead to significant delays in processing and may affect eligibility.
Another frequent error involves not signing the form. Many individuals forget to sign and date the CMS-40B, which is a crucial step. Without a signature, the form is considered incomplete, and the application cannot be processed.
People often overlook the importance of reviewing the instructions carefully. The CMS-40B form comes with specific guidelines that must be followed. Ignoring these instructions can lead to misunderstandings about what information is required, resulting in incomplete submissions.
Additionally, some applicants fail to provide the necessary supporting documentation. Depending on the circumstances, certain documents may be required to verify eligibility. Not including these can lead to delays or denials of coverage.
Another mistake is submitting the form without checking for updates. Regulations and requirements can change, and it’s essential to ensure that you are using the most current version of the CMS-40B. Using an outdated form can cause complications.
People sometimes rush through the process and do not take the time to double-check their answers. This can lead to inaccuracies that might seem minor but can have significant repercussions. Taking a moment to review the completed form can prevent many issues.
In some cases, applicants neglect to keep a copy of the submitted form. Having a record of what was sent can be invaluable if there are questions or issues later. This simple step can save time and frustration in the future.
Lastly, individuals may not follow up on their application status. After submitting the CMS-40B form, it is advisable to check in with the appropriate agency to ensure that everything is in order. Proactive communication can help address any potential problems early on.
Documents used along the form
The CMS-40B form is used for applying for Medicare Part B coverage. It is important to understand other related documents that may accompany this form during the application process. Below is a list of commonly used forms and documents that can be relevant.
- CMS-40A: This form is used to apply for Medicare Part A coverage. It helps individuals enroll in hospital insurance and is often submitted alongside the CMS-40B form.
- CMS-L564: This document serves as a request for employment information. It is used to verify eligibility for a Special Enrollment Period based on current or recent employment.
- CMS-5000: This form is the Medicare Enrollment Application. It is used for individuals who want to apply for Medicare or change their enrollment status.
- Proof of Citizenship or Legal Residency: Documentation such as a birth certificate or immigration papers may be required to establish eligibility for Medicare benefits.
These documents are crucial for ensuring a smooth application process for Medicare coverage. Proper preparation and submission of these forms can help avoid delays in receiving benefits.
Similar forms
The CMS-40B form is used to apply for Medicare Part B coverage. Similar to the CMS-40B, the CMS-40A form is also an application for Medicare. However, the CMS-40A specifically targets individuals who are eligible for Medicare due to age, while the CMS-40B focuses on those who qualify due to disability or other special circumstances. Both forms require personal information and documentation to verify eligibility, ensuring that applicants receive the appropriate healthcare benefits.
The SSA-1 form, known as the Application for Social Security Benefits, shares similarities with the CMS-40B in that it serves as an application for government benefits. While the SSA-1 is primarily focused on Social Security retirement or disability benefits, both forms require detailed personal information, such as work history and financial details. This information is essential for determining eligibility for the respective programs, ensuring that applicants are accurately assessed.
The CMS-1763 form, which is used to request a voluntary termination of Medicare Part B coverage, is another document that parallels the CMS-40B. While the CMS-40B initiates coverage, the CMS-1763 allows individuals to cancel it. Both forms involve similar processes, including the need for personal identification and reasons for the action taken. This ensures that the Centers for Medicare & Medicaid Services (CMS) can efficiently manage individuals' coverage status.
The CMS-855I form, which is an application for Medicare enrollment for individual providers, has a similar purpose to the CMS-40B in that it facilitates access to Medicare benefits. The CMS-855I is specifically designed for healthcare providers seeking to bill Medicare for services rendered. Both forms require comprehensive information about the applicant, including identification and qualifications, to ensure that only eligible individuals can participate in the Medicare program.
The Form SSA-44, also known as the Medicare Income-Related Monthly Adjustment Amount (IRMAA) Appeal form, is similar to the CMS-40B in that it addresses eligibility for Medicare-related benefits. While the SSA-44 is focused on appealing a determination regarding income-related adjustments, both forms require detailed financial information and personal identification. This ensures that the Social Security Administration can accurately assess the individual’s situation regarding Medicare costs.
Finally, the CMS-1490S form, used for requesting reimbursement for medical expenses not covered by Medicare, relates closely to the CMS-40B as both pertain to Medicare benefits. The CMS-1490S allows beneficiaries to seek reimbursement for out-of-pocket expenses, while the CMS-40B is the gateway to obtaining those benefits. Both forms require specific documentation and personal information, ensuring that the CMS can effectively process requests and maintain accurate records of beneficiary interactions.
Dos and Don'ts
When filling out the CMS-40B form, it's important to follow certain guidelines to ensure that the process goes smoothly. Below is a list of things you should and shouldn't do while completing this form.
- Do read the instructions carefully before starting.
- Do provide accurate and complete information.
- Do double-check your entries for any errors.
- Do sign and date the form where required.
- Do keep a copy of the completed form for your records.
- Don't leave any required fields blank.
- Don't use white-out or correction fluid on the form.
- Don't submit the form without reviewing it first.
- Don't forget to check for any additional documents that may need to be included.
By adhering to these guidelines, you can help ensure that your CMS-40B form is processed efficiently and accurately.
Misconceptions
The CMS-40B form is often misunderstood. Here are five common misconceptions about it:
- It is only for seniors. Many believe that only individuals over a certain age can use this form. In reality, it is available to anyone eligible for Medicare, regardless of age.
- Filling out the form guarantees coverage. Some think that simply submitting the CMS-40B ensures that they will receive Medicare coverage. However, eligibility is determined by specific criteria, and the form is just one part of the process.
- It can be submitted at any time. There is a misconception that the CMS-40B can be submitted whenever someone decides to apply for Medicare. In truth, there are specific enrollment periods when the form must be submitted to avoid penalties.
- It is a complicated form. Many people assume that the CMS-40B is difficult to complete. In fact, the form is straightforward and designed for easy understanding.
- It only applies to Medicare Part A. Some individuals think that the CMS-40B is relevant only for Medicare Part A. However, this form is specifically for those applying for Medicare Part B coverage.
Understanding these misconceptions can help ensure that individuals navigate the Medicare application process more effectively.
Key takeaways
The CMS-40B form is essential for individuals seeking to apply for Medicare Part B. Understanding how to fill it out correctly can streamline the application process. Here are key takeaways regarding the form:
- Eligibility: Ensure you meet the eligibility requirements for Medicare Part B before filling out the form.
- Personal Information: Provide accurate personal details, including your name, address, and Social Security number.
- Signature: Don’t forget to sign and date the form. An unsigned form may delay processing.
- Submission Method: Submit the completed form to your local Social Security office. You can do this by mail or in person.
- Deadlines: Be aware of the enrollment periods. Missing a deadline can result in penalties or delayed coverage.
- Review: Double-check all information for accuracy before submission. Mistakes can cause significant delays.
- Tracking: Keep a copy of the submitted form for your records. This can be useful for tracking the status of your application.
- Assistance: If you have questions, consider contacting the Social Security Administration for help with the form.