This form is your application for Medicare Part B (Medical Insurance). You can use this form to sign up for Part B: • During your Initial Enrollment Period (IEP) when you’re first eligible for Medicare • During the General Enrollment Period (GEP) from January 1 …

Get the forms you need to sign up for Part B including CMS-40B, CMS-L564, CMS-10797, and CMS-10798.

This form is your application for Medicare Part B (Medical Insurance). You can use this form to sign up for Part B: During your Initial Enrollment Period (IEP) when you’re first eligible for Medicare; During the General Enrollment Period (GEP) from …

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.

how and why in the Remarks section, and include proof or documentation with this form.) YES NO 9. Remarks: CMS-40B (01/24) 2 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Form Approved OMB No. 0938-1230 Expires: 01/25. 10. Written Signature (DO NOT PRINT) SIGN HERE. 11. Date Signed / /

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

Nov 29, 2023 · More recent filings for OMB 0938-1230 can be found here: Is this a Common Form? No. Available Electronically? Can Be Submitted Electronically?

Form Approved OMB No. 0938-1230 Expires: 01/25 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES APPLICATION FOR ENROLLMENT IN MEDICARE PART B (MEDICAL INSURANCE) CMS-40B (01/24) 2 10. Written Signature (DO NOT PRINT) SIGN HERE 11. Date Signed / / 12. Signature of Witness 13. …

Form Approved. OMB No. 0938-1230. APPLICATION FOR ENROLLMENT IN MEDICARE PART B (MEDICAL INSURANCE) 1. Your Social Security Claim Number – –

This form is your application for Medicare Part B (Medical Insurance). You can use this form to sign up for Part B: • During your Initial Enrollment Period (IEP) when you’re first eligible for Medicare • During the General Enrollment Period (GEP) from January 1 …