Form 40B Details

If you're a small business owner in Indiana, you may be wondering what Form 40B is and how it affects your taxes. This form is used to calculate the state's adjusted gross income tax, so it's important that you understand it and make sure your return is filed correctly. In this blog post, we'll explain what Form 40B is and provide some tips on how to complete it. We'll also highlight some of the changes for the 2018 tax year.

Here is the details regarding the file you were in search of to complete. It will tell you how much time you'll need to complete form 40b, what parts you need to fill in and some other specific details.

QuestionAnswer
Form NameForm 40B
Form Length2 pages
Fillable?Yes
Fillable fields26
Avg. time to fill out5 min 46 sec
Other namessocial security form 40b, hcfa 40b form, form 40b pdf, medicare form cms 40b printable form

Form Preview Example

APPLICATION FOR ENROLLMENT IN MEDICARE

THE MEDICAL INSURANCE PROGRAM

SOCIAL SECURITY CLAIM NUMBER/BIC (beneficiary identification code)

DO YOU WISH TO ENROLL FOR MEDICAL INSURANCE UNDER MEDICARE?

YES – Part B Only

CLAIMANT'S NAME

Last Name

First Name

Middle Initial

PRINT SOCIAL SECURITY NUMBER HOLDER'S NAME IF DIFFERENT FROM YOURS

MAILING ADDRESS (NUMBER AND STREET, PO BOX, OR ROUTE)

IF THIS IS A CHANGE OF ADDRESS, CHECK HERE

CITY, STATE, AND ZIP CODE

TELEPHONE NUMBER

 

( )

 

 

 

 

 

WRITTEN SIGNATURE (DO NOT PRINT)

DATE SIGNED

 

SIGN HERE __________________________

___ ___/___ ___/___ ___

MM

DD

YY

 

 

 

 

 

IF THIS APPLICATION HAS BEEN SIGNED BY MARK (X), A WITNESS WHO KNOWS THE APPLICANT MUST SUPPLY THE INFORMATION REQUESTED BELOW.

SIGNATURE OF WITNESS

DATE SIGNED

___ ___/___ ___/___ ___

MM DD YY

ADDRESS OF WITNESS

REMARKS

I am still working and covered by my EGHP. I want part B coverage to begin ____________.

Other: I want to enroll in part B only.

TO:

Form HCFA-40B

PRIVACY ACT NOTICE

The Social Security Administration (SSA) is authorized to collect information on this form under sections 1836, 1840, and 1872 of the Social Security Act, as amended (42 U.S.C. 1395o, 1395s, and 1395ii). The information on this form is needed to enable SSA and the Health Care Financing Administration (HCFA) to determine if you are entitled to supplementary medical insurance benefits. While completing this form is voluntary, failure to provide all or part of this information will result in your not being enrolled for medical insurance under Medicare. You should be aware that the information you furnish can be released by way of "routine uses" published in the Federal Register. Because they are too numerous to list here, SSA can furnish you with additional information upon request. You should also be aware that the information you provide on this form may be verified by a way of a computer match (Pub. Law 100-503).

SPECIAL MESSAGE FOR INDIVIDUAL APPLYING

FOR MEDICAL INSURANCE UNDER MEDICARE

This form is your application for the Medical Insurance part of Medicare. It can be used either during your initial enrollment period, during any general enrollment period, or during a special enrollment period to which you may be entitled if you are covered under an employer's group health plan. Once you have completed this form, please return it to your local Social Security office. A completed form must be received for each eligible dependent.

Your initial enrollment period lasts for 7 months. It begins 3 months before the month you reach age 65 (or 3 months before the 25th month you have received Social Security disability benefits) and it ends 3 months after you reach age 65 (or 3 months after the 25th month you received Social Security disability benefits). To have medical insurance start in the month you are 65 (or the 25th month of disability insurance benefits), you must sign up in the first 3 months of your initial enrollment period. If you sign up in any of the remaining 4 months, your medical insurance will start later.

If you do not file during your initial enrollment period, you can file any time after that during a general enrollment period which is the first 3 months of every year. If you sign up in a general enrollment period, your medical insurance begins July 1 of that year. However, when you file in a general enrollment period, your premium may be subject to a penalty increase. For each 12 month period elapsing between the end of your initial enrollment period and the end of the general enrollment period in which you file, your premium will be increased 10 percent.

If you are age 65 or older and employed, or the spouse of an employed person, and are covered under an employer group health plan (EGHP), you may be eligible to enroll during any of the 8 months after employment is terminated or, if earlier, after your employer group health plan coverage ends for any reason. You may also enroll at any time while you are still covered under a group health insurance plan based on your own work or that of your spouse. If you are under age 65, entitled to Medicare based on disability, and are covered under an employer's group health plan based on your own current employment or the current employment of your spouse, or are covered under a large group health plan based on your own current employment or the current employment of any family member, you may be eligible to enroll while you are still covered by the plan or during a special 8 month enrollment period which begins when the employer group health plan coverage ends or the employment ends, whichever occurs first. If you are disabled and your health plan notified you that Medicare will now be the primary payer of health insurance benefits, you may be eligible for a special enrollment period. Your medical insurance coverage will begin sooner under these special enrollment provisions than it will if you delay enrollment until the following general enrollment period. Also, you may be eligible under these special provisions for a reduction in the premium surcharge or penalty that usually applies to people who delay their enrollment in medical insurance under Medicare. If you are covered under an employer's group health plan (EGHP) and think that you may be eligible for a special enrollment period, please discuss your enrollment eligibility with a representative at the Social Security office.

How to Edit Form 40B

This PDF editor makes it easy to complete the 40b form document. It's possible to generate the form without delay through these simple actions.

Step 1: Click on the button "Get Form Here".

Step 2: Once you have entered your 40b form edit page, you'll discover all actions it is possible to use regarding your document in the top menu.

If you want to fill in the template, type in the information the software will request you to for each of the appropriate segments:

hcfa 40b form empty fields to complete

Type in the required details in the segment WRITTEN SIGNATURE (DO NOT PRINT), DATE SIGNED / / MM DD YY, ADDRESS OF WITNESS REMARKS, I am still working and covered by, Other: I want to enroll in part B, TO:, and Form HCFA-40B.

Entering details in hcfa 40b form stage 2

Step 3: Press the Done button to make sure that your completed file is available to be transferred to any type of electronic device you end up picking or mailed to an email you indicate.

Step 4: Try to get as many duplicates of the file as you can to remain away from future troubles.

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