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Submit an application. You can apply online when you’re ending an employer group health plan. During this Special Enrollment Period, you can apply any time of year. Start application. Other times to sign up. When you have a special situation. In certain situations, Medicare offers different enrollment periods for a limited time.
Get the forms you need to sign up for Part B including CMS-40B, CMS-L564, CMS-10797, and CMS-10798.
APPLICATION FOR ENROLLMENT IN MEDICARE PART B (MEDICAL INSURANCE) WHO CAN USE THIS APPLICATION? People with Medicare who have Part A but not Part B. NOTE: If you do not have Part A, do not complete this form. Contact Social Security if you want to apply for Medicare for the first time. WHEN DO YOU USE THIS APPLICATION? Use this form:
DEPARTMENT OF HEALTH AND HUMAN SERVICES. CENTERS FOR MEDICARE & MEDICAID SERVICES. Form Approved. OMB No. 0938-0787. REQUEST FOR EMPLOYMENT INFORMATION. SECTION A: To be completed by individual signing up for Medicare Part B (Medical Insurance) 1. Employer's name. 2. Date / / 3. Employer’s Address. City.
You will need: • Your Medicare Number. • Your current address and phone number. WHAT HAPPENS NEXT? Send your completed and signed application to your local Social Security office. If you have questions, call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. HOW DO YOU GET HELP WITH THIS APPLICATION?
Mail your application by March 31, 2024 (must be postmarked by this date) using the envelope in this packet. You can also sign up by: 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.
Apply online to sign up for Part B if you already have Part A. Have the employer fill out form CMS-L564. Send the completed form to your local Social Security office by fax or mail. If the employer can’t fill it out, complete Section B of the CMS-L564 form as best you can, but don’t sign it.
