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WHEN DO YOU USE THIS APPLICATION? Use this form: • If you’re in your IEP and refused Part B or did not sign up when you applied for Medicare, but now want Part B. • If you want to sign up for Part B during the General Enrollment Period (GEP) from January 1 – March 31 each year. • If you’re eligible for a Special Enrollment Period (SEP).
This form is your application for Medicare Part B (Medical Insurance). You can use this form to sign up for Part B: During your Initial Enrollment Period (IEP) when you’re first eligible for Medicare; During the General Enrollment Period (GEP) from January 1 through March 31 of each year
Get the forms you need to sign up for Part B including CMS-40B, CMS-L564, CMS-10797, and CMS-10798.
Fill out the Application for Enrollment in Medicare Part B (CMS-40B) (PDF). If you are applying during the Special Enrollment Period, also fill out the Request for Employment Information (CMS-L564) (PDF).
This form is your application for Medicare Part B (Medical Insurance). You can use this form to sign up for Part B if you’re eligible for an SEP and you’re covered under a GHP based on current employment.
Downloading Form CMS-40B (Application for Enrollment in Medicare Part B) at Medicare.gov/basics/forms-publications-mailings/forms/enrollment. Complete the application and sign it. Return the completed application to your local Social Security ofice. Calling Social Security at 1-800-772-1213.
SPECIAL MESSAGE FOR INDIVIDUAL APPLYING FOR PART B . This form is your application for Medicare Part B (Medical Insurance). You can use this form to sign up for Part B: • During your Initial Enrollment Period (IEP) when you’re first eligible for Medicare • During the General Enrollment Period (GEP) from January 1 through March 31 of each year
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