Fillable Form CMS 40B
CMS 40B Form is an Application for Enrollment in Medicare used by US resident to apply for health insurance when they turn 65.
What is Form CMS-40B?
Form CMS-40B, or Application for Enrollment in Medicare Part B (Medical Insurance), is only for people with Medicare Part A but not Medicare Part B. Individuals who do not have Medicare Part A cannot enroll in Medicare Part B.
A form by the Department of Health and Human Services — Centers for Medicare and Medicaid Services, it provides healthcare benefits to enrolled individuals. Among the benefits are outpatient care, preventive services, use of medical equipment, part-time health services, and physical therapy.
Unlike Medicare Part A that comes without cost, given that an individual paid Medicare tax, Medicare Part B requires an individual to pay monthly premiums for the duration of his or her coverage.
According to the Department of Health and Human Services — Centers for Medicare and Medicaid Services, an individual can use Form CMS-40B to sign up for Medicare Part B:
The Initial Enrollment Period begins three months before the month of birth of an individual and ends three months after the month of his or her birthday. This period lasts for seven months. In some cases, if an individual has Medicare due to disability, his or her IEP begins three months before the 25th month of getting Social Security Benefits and ends three months after the 25th month of getting Social Security Benefits.
The General Enrollment Period happens from January 1 through March 31 of each year; however, enrollment during this period requires payment for late enrollment, as the enrollment for Medicare Part B should be done during the IEP. A late enrollment fee is 10% of each full 12-month period that you do not have Medicare Part B but you were eligible to sign up.
The Special Enrollment Period is for individuals covered under a GHP due to their or their spouse’s employment. The coverage even extends for eight months after the employment or coverage ceases. To apply during this period, an individual must submit Form CMS-L564, or Request for Employment Information, completed by your employer along with Form CMS-40B during application. The most common SEPs apply to the working-aged, disabled, and international volunteers.
How to Fill Out Form CMS-40B?
The single-page Form CMS-40B requires important information to complete the application, such as Medicare Number, personal information, and contact details of the applicant.
Item 1 asks your Medicare Number.
Item 2 asks you to mark the checkbox if you wish to apply for Medicare Part B or Medical Insurance.
Item 3 asks you to provide your full legal name.
Item 4 asks you to provide the number and street, P.O. Box, or route of your mailing address.
Item 5 asks you to provide the city, state, and ZIP code of your mailing address.
Item 6 asks you to provide your phone number, including area code.
Item 7 asks your signature. If you’re unable to sign, you may mark an “X” in this field. In this case, you will need a witness and the witness must complete questions 11, 12, and 13.
Item 8 asks the date when you signed the form.
If you signed Form CMS-40B with a mark (x), a witness who knows you must supply the information requested in the succeeding items:
Item 9 asks the signature of the witness.
Item 10 asks the date when the witness signed the form.
Item 11 asks the address of the witness.
Item 12 asks any remarks or comments to clarify information about your application, if applicable.
Submission
Submit Form CMS-40B to your local Social Security office. If you are signing up for a SEP, include Form CMS-L564.