Edit
Fill out
Sign
Export or Print
Download your fillable CMS-40B in  PDF
CMS-40B

The Original Medicare program in the United States comprises two parts: Part A (Hospital Insurance) and Part B (Medical Insurance). The CMS-40B Form is also recognized as Application For Enrollment in Medicare (Part B). Hereunder, we will tell you more about the purpose of this document and its filing requirements.

Medicare is a governmental health program devoted to creating individual insurance plans for certain groups of people. There are three main medical insurance categories:

  • Seniors of 65 years old or older;
  • People under 65 years but with specific health conditions;
  • Individuals suffering from renal failure.

The program helps cover various medical services, but it does not cover all of them. All applicants will have to cover some medical expenses themselves, especially the long-term ones (like in-hospital care).

Difference Between Part A and Part B of Medicare

Even though both Medicare parts belong to the same health insurance program, they have different features and characteristics. The most crucial difference is service coverage.

Medicare Part A covers a list of possible medical services, including:

  1. Home health services (physical and occupational therapy);
  2. Skilled nursing (intravenous injections, physical and mental conditions check);
  3. Care in hospitals (meals, drugs, general nursing);
  4. Hospice care (pain relief, symptoms management).

To expand the area of medical services provided by your insurance plan, you can also enroll in Part B. With Medicare Part B, you will have access to the following services:

  1. Ambulance services (transportation by an airplane or helicopter if needed, skilled nursing facilities);
  2. Durable medical equipment (blood sugar monitors, infusion pumps and supplies, oxygen equipment);
  3. Limited outpatient prescription drugs (some antigens, injectable osteoporosis drugs, infused drugs);
  4. Clinical research.

When to Use the Application For Enrollment?

You should use the CMS-40B Form to apply for Medicare Part B, but only if you already are a Medicare Program Part A participant.

People usually apply for Medicare Part B when their Initial Enrollment Period (IEP) starts. The IEP begins three months before the applicant’s 65th birthday, lasts for a month after the birthday, and then ends three months afterward. Thus, the overall IEP is seven months long. Please note that if you choose not to apply for Medicare enrollment during your IEP but decide to do so later, you will have to pay a fine.

There is also a General Enrollment Period (GEP), which lasts annually from the 1st of January until the 31st of March. Those willing to apply for enrollment during their GEP may also use the CMS-40B Form to sign up.

Other CMS Forms

Check some other CMS forms readily available for editing in our tool. Moreover, do not forget that you can upload, fill out, and edit any PDF document at FormsPal.


How to Complete the CMS-40B Form?

You need to obtain the relevant application form before moving on with the process. We strongly advise you to use our latest software tools and developments to build the document you need. To make the process even more straightforward and convenient for you, we also created an online document editor to fill out the application online. Please use the recommendations given below to do so.

Indicate Your Medicare Number

If you already are a part of the US Medicare Program, fill in your Medicare Number in Box 1. If you are not a participant yet, please leave this field empty. Check the “YES” box if you are willing to apply for Medicare Part B or leave the space empty if you do not have such intention.

step 1 indicate your medicare number - filling out a cms-40b
Fill Out Personal Information

Points from 3 to 8 require that you fill out the necessary information about yourself, including:

  • Your Full Legal Name

Please use the name under which you have applied for Medicare Part A. Enter your last name first, then proceed to your first name, and put the middle name in the end. Leave the middle name box empty if you do not have one.

  • Mailing Address

This section requires that you fill out your physical address, including street, building number, postal office box, and route (if applicable).

  • City of Residence

Write down or type in the name of the city you live in, including the state and zip code.

  • Contact Daytime Phone Number

Fill in your 10-digit contact phone number with the area code.

step 2 fill out personal information - filling out a cms-40b
Put Your Signature

Sign the form with the signature you use to sign any official document. If you cannot sign the form with your signature for some reason, just put the “X” mark in a corresponding field. Please note that you might need a witness to prove the lawfulness of such a form. Ask a witness to fill out questions №9, 11, and 12.

step 3 put your signature - filling out a cms-40b
Fill in the Date of Applying (Date Signed)

Put the current date in the day-month-year format in the designated order (as shown below).

step 4 fill in the date of applying (date signed) - filling out a cms-40b
Recommendations for Witnesses

As mentioned above, you must use a witness if you cannot sign the form yourself. The witness must answer specific questions and enter the responses in the corresponding fields of the application form. First of all, the witnesses should put their signature in Box 9 (as shown below).

step 5.1 recommendations for witnesses - filling out a cms-40b
After completion, the witness must provide their physical address and fill out the “Date Signed” field.

step 5.2 recommendations for witnesses - filling out a cms-40b
Additional Information

You may use the “Remarks” field to enter any additional information regarding the applicant’s enrollment in Medicare Part B.

step 6 additional information - filling out a cms-40b

Steps to Take After Completing the Application Form

You have two options to receive your Part B medical insurance when you complete the CMS-40B application form.

You can either mail the completed Application for Enrollment in Medicare Part B form to your local Security Office or apply online.