Fillable Form CMS 40B

What is Form CMS-40B?

Form CMS-40B is a Department of Health and Human Services — Centers for Medicare and Medicaid Services document that individuals should use to apply for Medicare Part B. Individuals who do not have Medicare Part A cannot enroll in Medicare Part B; hence, they cannot use Form CMS-40B.

Among other healthcare benefits, Medicare Part B covers outpatient care, preventive services, use of medical equipment, part-time health services, and physical therapy. It requires monthly premiums. On the other hand, Medicare Part Acomes at no cost, provided that an individual paid Medicare tax. In general, most Americans enroll in Medicare Part A when they turn 65.

According to the instructions on Form CMS-40B. You can complete and submit it to sign up for Medicare Part B:

• During your Initial Enrollment Period (IEP) or when you are first eligible for Medicare — It starts three months before the month of your 65th birthday and ends three months after the month of your 65th birthday.
• During the General Enrollment Period (GEP) —It runs from January 1 through March 31 of each year. Enrolling during GEP has a late enrollment penalty. 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.
• If you are eligible for a Special Enrollment Period (SEP), such as if you are covered under a group health plan (GHP) based on current employment. You can also qualify for SEP if your spouse is receiving GHP from his or her work. It extends for eight months after employment or coverage ceases — You need to 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.

In addition, use this form:

• If you are in your IEP and live in Puerto Rico.
• If you are in your IEP and refused Medicare Part B or did not sign up when you applied for Medicare, but now want Medicare Part B.
• If you want to sign up for Medicare Part B during the GHP from January 1 to March 31.
• If you refused Medicare Part B during your IEP due to having a GHP coverage; you may sign up during your 8-month SEP.
• If you have Medicare due to disability and refused Medicare Part B during your IEP due to having a GHP coverage.
• If you want to sign up during your 8-month SEP.

How to Fill Out Form CMS-40B?

Form CMS-40B is a single-page form that requires your Medicare Number and personal information. Make sure all the details you will provide are accurate for your application to be processed without problems.

Item 1
Provide your Medicare Number

Item 2
Check the box if you wish to sign up for Medicare Part B or Medical Insurance.

Item 3
Provide your full last name following the format: Last Name, First Name, and Middle Name.

Item 4
Provide the number and street, P.O. Box, or Route of your mailing address.

Item 5
Provide the city, state, and ZIP code of your mailing address.

Item 6
Provide your phone number, including area code.

Item 7
Provide 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
Provide the date when you signed the form.

If Form CMS-40B has been signed by mark (x), a witness who knows the applicant must supply the information requested in the succeeding items:

Item 9
Provide the signature of the witness.

Item 10
Provide the date when the witness signed the form.

Item 11
Provide the address of the witness.

Item 12
Provide any remarks or comments to clarify information about your application.

Submission

Once you are done with Form CMS-40B, submit it to your local Social Security office. Do not forget to include Form CMS-L564 if you are signing up in a SEP.