Form CMS-40B, Application for Enrollment in Medicare Part B Completed Form Examples and Samples
Discover a detailed example of a completed CMS-40B form used for Medicare Part B enrollment for a retiree. This guide includes personal details, the requested enrollment effective date, and a signature to ensure a seamless application process.
CMS-40B Example – Enrollment for Retiree
How this form was filled:
An example of a filled CMS-40B form for a retiree enrolling in Medicare Part B. The form includes personal details, requesting enrollment effective date, and a signature.
Information used to fill out the document:
- Applicant’s Full Name: Jane Smith
- Medicare Number: 1EG4-TE5-MK73
- Date of Birth: 06/12/1955
- Street Address: 456 Elm Street
- City: Springfield
- State: IL
- ZIP Code: 62701
- Telephone Number: 555-123-4567
- Effective Date of Coverage: 01/01/2025
- Signature: Jane Smith
- Date Signed: 12/15/2024
What this filled form sample shows:
- Accurate completion of personal information and Medicare number
- Specifies a clear effective date of coverage
- Properly formatted signature and date
- Demonstrates filling the form for an early 2025 enrollment
Form specifications and details:
| Use Case: | Retiree enrolling in Medicare Part B |
