Application for Enrollment in Medicare Part B (Medical Insurance)
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
Form Approved
OMB No. 0938-1230
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:
• If you’re in your Initial Enrollment Period (IEP) and live in
Puerto Rico. You must sign up for Part B using 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 refused Part B during your IEP because you had
group health plan (GHP) coverage through your or your
spouse’s current employment. You may sign up during
your 8-month Special Enrollment Period (SEP).
• If you have Medicare due to disability and refused Part
B during your IEP because you had group health plan
coverage through your, your spouse or family member’s
current employment.
• You may sign up during your 8-month SEP.
NOTE: Your IEP lasts for 7 months. It begins 3 months before
your 65th birthday (or 25th month of disability) and ends
3 months after you reach 65 (or 3 months after the 25th
month of disability).
WHAT INFORMATION DO YOU NEED TO
COMPLETE THIS APPLICATION?
You will need:
• Your Social Security Claim Number
• Your current address and phone number
• Form CMS-L564 ”Request for Employment Information”
completed by your employer if you’re signing up in a SEP.
WHAT HAPPENS NEXT?
Send your completed and signed application to your local
Social Security office. If you sign up in a SEP, include the
CMS-L564 with your Part B application. 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?
• Phone: Call Social Security at 1-800-772-1213. TTY users
should call 1-800-325-0778.
• En español: Llame a SSA gratis al 1-800-772-1213 y oprima
el 2 si desea el servicio en español y espere a que le
atienda un agente.
• In person: Your local Social Security office. For an office
near you check www.ssa.gov.
REMINDERS
• If you sign up for Part B, you must pay premiums for
every month you have the coverage.
• If you sign up after your IEP, you may have to pay a late
enrollment penalty (LEP) of 10% for each full 12-month
period you don’t have Part B but were eligible to sign up.
CMS-40B (04/17) 1
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