Form CMS-40B, Application for Enrollment in Medicare Part B Completed Form Examples and Samples
Explore a detailed example of Form CMS-40B, showcasing how to correctly fill out the Application for Enrollment in Medicare Part B. This step-by-step guide features essential elements like personal details, Medicare number, and requested start date, providing a practical sample for individuals enrolling in Medicare Part B.
Form CMS-40B Example – Individual Enrollment in Medicare Part B
How this form was filled:
This example demonstrates how an individual applies for Medicare Part B using Form CMS-40B. The form includes the applicant's personal details, current Medicare information, and requested enrollment period.
Information used to fill out the document:
- Applicant’s Name: John Smith
- Mailing Address: 456 Elm Street, Anytown, USA
- Phone Number: (555) 123-4567
- Medicare Number: 1EG4-TE5-MK72
- Start Date: 04/01/2025
- Signature: John Smith
- Date Signed: 03/15/2025
What this filled form sample shows:
- Accurate completion of applicant's personal details including address and phone number
- Correct Medicare number format for existing Medicare holders
- Clear indication of the requested start date for Medicare Part B
- Properly formatted signature and date
Form specifications and details:
| Use Case: | Individual enrolling in Medicare Part B |
| Form Title: | Application for Enrollment in Medicare Part B |
| Year: | 2025 |
| Relevant For: | New Medicare Part B enrollees |
