WebThis 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
WebUse 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).
WebThis 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.
WebFill 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).
WebThis information is needed for SSA and the Centers for Medicare & Medicaid Services (CMS) to determine if you are entitled to Supplementary Medical Insurance (Part B). Completing this form is voluntary, but you will not be enrolled in Part B if you do not provide all of the required information.
WebFill out form CMS-40B. Send the completed form to your local Social Security office by fax or mail. Download Form. Contact Social Security to submit your forms or get help: Send completed forms to your local Social Security office by fax or mail. Call 1-800-772-1213. TTY users can call 1-800-325-0778.
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EN-05-10012- How to Apply for Medicare Part B During Your …
Webcan complete and upload Form CMS-L564 (Request for Employment Information), or provide written notification (a letter, fax, or email) from the employer, GHP, or LGHP. 2. Fax your CMS-40B and employer-signed CMS-L564 (or written notification) to your local Social Security office. 3. Mail your CMS-40B and employer-signed CMS-L564 (or written ...
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Sign up for Medicare Part B Online, by Fax or Mail | SSA
WebAug 6, 2020 · You can complete form CMS-40B ( Application for Enrollment in Medicare – Part B [Medical Insurance]) and CMS-L564 (Request for Employment Information) online. You can also fax the CMS-40B and CMS-L564 to 1-833-914-2016; or return forms by mail to your local Social Security office .
WebDownloading 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. TTY users can call 1-800-325-0778.