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Application for Enrollment in Medicare - Part B

Name: Printable blank Application for Enrollment in Medicare - Part B CMS 40B
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1. What is a Part B CMS 40B Form?

The fillable Part B CMS 40B Form (Application for Enrollment in Medicare Part B (Medical Insurance)) is used for applying to use the benefits of Medicare Part B. According to the law, several categories of American citizens have the right to receive these benefits. Your valid medicare number is required. If you are under a group health plan by your employer, attach the request for employment information (Form CMS-L564/CMS-R-297).

2. What I need the Part B CMS 40B Form for?

You have to submit this medical form in order to apply for Medicare Part B;
Fill when you are in your Initial Enrollment Period (IEP);
Fill when you are in the General Enrollment Period (GEP);
File if you qualify for the Special Enrollment Period (SEP);
File if you are under the Special Enrollment Period (SEP).

You can download Part B CMS 40B Form official PDF version or print it directly from PDFLiner’s library. Else, you can fill the form online in our editor for free within the 10-day trial period.

3. How to fill out Part B CMS 40B Form?

Application for Enrollment in Medicare - Part B Screenshot

The blank of this form must contain the following data:

Your valid Medicare number;
Consent to sign up for Medicare Part B;
Your full name;
Full mailing address;
Your city, state, and Zip;
Your contact phone number;
The date and your real signature along with the signature of one witness;
Complete box 12 in written form if you want to add any remarks to your application.

Application for Enrollment in Medicare - Part B Screenshot 2

4. Organizations that work with Part B CMS 40B Form:

Department of Health and Human Services;
Centers for Medicare and Medicaid Services.

Form Versions

2019 Fillable Application for Enrollment in Medicare - Part B CMS 40B (2019) Fill Out Form

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