Administration at 1-800-772-1213 to enroll in Medicare or to ask questions about whether you are eligible. You can also visit their web site at www.socialsecurity.gov.
The Medicare.gov Web site also has a tool to help you determine if you are eligibile for Medicare and when you can enroll. It is called the Medicare Eligibility Tool.
If you already receive benefits from Social Security:
If you already get benefits from Social Security or the Railroad Retirement Board, you are automatically entitled to Medicare Part A (Hospital Insurance) and Part B (Medical Insurance) starting the first day of the month you turn age 65. You will not need to do anything to enroll. Your Medicare card will be mailed to you about 3 months before your 65th birthday. If your 65th birthday is February 20, 2010, your Medicare effective date would be February 1, 2010. (Note: if your birthday is on the 1st day of any month, Medicare Part A and Part B will be effective the 1st day of the prior month. For example, if your 65th birthday is February 1, 2010, your Medicare effective date would be January 1, 2010.)
If you are not getting Social Security benefits:
If you are not getting Social Security benefits, you can apply for retirement benefits online. If you would like to file for Medicare only, you can apply by calling 1-800-772-1213.
If you are under age 65 and disabled, and have been entitled to disability benefits under Social Security or the Railroad Retirement Board for 24 months, you will be automatically entitled to Medicare Part A and Part B beginning the 25th month of disability benefit entitlement. You will not need to do anything to enroll in Medicare. Your Medicare card will be mailed to you about 3 months before your Medicare entitlement date. (Note: If you are under age 65 and have Lou Gehrig's disease (ALS), you get your Medicare benefits the first month you get disability benefits from Social Security or the Railroad Retirement Board.) For more information about enrollment, call the Social Security Administration at 1-800-772-1213 or visit the Social Security web site. See also Social Security's Medicare FAQs.
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 Medicare 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.
You have the right to get Medicare information in an accessible format, like large print, Braille, or audio. You also have the right to file a complaint if you feel you’ve been discriminated against. Visit //www.medicare.gov/about-us/accessibilitynondiscrimination-notice, or call 1-800-MEDICARE (1-800-633-4227) for more information. TTY users can call 1-877-486-2048.
CMS-40B (04/19)
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
Form Approved
OMB No. 0938-1230
Expires: 02/20
APPLICATION FOR ENROLLMENT IN MEDICARE PART B (MEDICAL INSURANCE)
1. Your Medicare Number
2. Do you wish to sign up for Medicare Part B (Medical Insurance)? YES
3. Your Name (Last Name, First Name, Middle Name)
4. Mailing Address (Number and Street, P.O. Box, or Route)
5. City
State
Zip code
6. Phone Number (including area code) () -
7. Written Signature (DO NOT PRINT)
8. Date Signed / /
IF THIS APPLICATION HAS BEEN SIGNED BY MARK (X), A WITNESS WHO KNOWS THE APPLICANT
MUST SUPPLY THE INFORMATION REQUESTED BELOW.
9. Signature of Witness
10. Date Signed / /
11. Address of Witness
12. Remarks
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1230. The time required to complete this information is estimated to average 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.