This form contains 47 fields organized into 10 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name	Type	Description
Citizenship
8. Are you a US citizen? Select one:_Yes	RadioButton	Select 'Yes' if you are a US citizen.
Citizenship Information
8. Are you a US citizen? Select one:_No	RadioButton	Select 'No' if you are not a US citizen.
Medicare Enrollment
Medicare Part B_Yes	RadioButton	Select this option if you are enrolling in Medicare Part B.
Medicare Part B_No	RadioButton	Select this option if you are not enrolling in Medicare Part B.
Medicare Part B_Unknown	RadioButton	Select this option if you are unsure about enrolling in Medicare Part B.
Personal Information
1 Print Your Name Last Name First Name Middle Name	Text	Enter your full name, including last name, first name, and middle name.
1a. If your name at birth was different, please enter your name at birth	Text	If your name at birth was different from your current name, enter your birth name here.
Sex - Male	CheckBox	Check this box if you are male.
Sex - Female	CheckBox	Check this box if you are female.
Social Security Number - first 3 digits	Text	Enter the first 3 digits of your Social Security Number.
Social Security Number - second 2 digits	Text	Enter the middle 2 digits of your Social Security Number.
Social Security Number - last 4 digits	Text	Enter the last 4 digits of your Social Security Number.
4 Date of Birth MMDDYYYY	Text	Enter your date of birth in MMDDYYYY format.
4a. State or Country of Birth	Text	Enter the state or country where you were born.
4b. Record of Birth	Text	Provide a record of your birth, such as a birth certificate.
Residency History
tarting with your current address	Text	Enter the address of your current residence and any other places you have lived in the last 5 years.
a. Date Residence Began MMDDYYYY	Text	Enter the date when you began residing at your current address in MMDDYYYY format.
a. Date Residence Ended MMDDYYYY	Text	Enter the date when you ended residing at your current address in MMDDYYYY format.
b. Write the address for your places of residence in the last 5 years starting with your current address	Text	Enter the address of your previous residence and any other places you have lived in the last 5 years.
b. Date Residence Began MMDDYYYY	Text	Enter the date when you began residing at your previous address in MMDDYYYY format.
b. Date Residence Ended MMDDYYYY	Text	Enter the date when you ended residing at your previous address in MMDDYYYY format.
c. Write the address for your places of residence in the last 5 years starting with your current address	Text	Enter the address of another previous residence and any other places you have lived in the last 5 years.
c. Date Residence Began MMDDYYYY	Text	Enter the date when you began residing at another previous address in MMDDYYYY format.
c. Date Residence Ended MMDDYYYY	Text	Enter the date when you ended residing at another previous address in MMDDYYYY format.
Residency Status
made your home in the United States Select One_Yes_3	RadioButton	Select 'Yes' if you have made your home in the United States.
made your home in the United States Select One_No_3	RadioButton	Select 'No' if you have not made your home in the United States.
the United States Select One_Yes_4	RadioButton	Select 'Yes' if you have made your home in the United States.
the United States Select One_No_4	RadioButton	Select 'No' if you have not made your home in the United States.
Signature
12. Signature	Signature	Provide your signature to confirm the information provided in the form.
13. Date Signed (month)	Text	Enter the month when you signed the form (2 digits). Max length: 2 characters
13. Date Signed (month) b	Text	Enter the month when you signed the form (2 digits). Max length: 2 characters
Signature Information
13. Date Signed (day)	Text	Enter the day of the month when the form was signed. Max length: 2 characters
13. Date Signed (day) b	Text	Enter the day of the month when the form was signed. Max length: 2 characters
13. Date Signed (year) 1	Text	Enter the year when the form was signed. Max length: 4 characters
13. Date Signed (year) 2	Text	Enter the year when the form was signed. Max length: 4 characters
13. Date Signed (year) 3	Text	Enter the year when the form was signed. Max length: 4 characters
13. Date Signed (year) 4	Text	Enter the year when the form was signed. Max length: 4 characters
Witness Information
14. Address of Witness	Text	Enter the address of the witness.
14a City, State, Zip	Text	Enter the city, state, and ZIP code of the witness.
15. Signature of Witness	Signature	Provide the signature of the witness.
15a. Date Signed	Text	Enter the date when the witness signed the form.
15b. Address of Witness	Text	Enter the address of the witness.
Work History
law administered by the office of Personnel Management_Yes_2	RadioButton	Select this option if you or your spouse receive a monthly annuity under the Federal Civil Service Retirement Act or other law administered by the Office of Personnel Management.
Do you or your spouse receive a mothly annuity under the Federal Civil Service Retirement Act, or other law administered by the office of Personnel Management	Text	Indicate whether you or your spouse receive a monthly annuity under the Federal Civil Service Retirement Act or other law administered by the Office of Personnel Management.
law administered by the office of Personnel Management_No_2	RadioButton	Select this option if you or your spouse do not receive a monthly annuity under the Federal Civil Service Retirement Act or other law administered by the Office of Personnel Management.
6a. If yes, provide the civil service annuity number for you or your spouse	Text	If you answered yes to the previous question, provide the civil service annuity number for you or your spouse.
6b. If you provided your spouse’s number, is he or she enrolled in	Text	If you provided your spouse’s civil service annuity number, indicate whether he or she is enrolled in Medicare Part B.

Form CMS-4040, Request for Enrollment in Medicare Part B Instructions