Form CMS-40B, Application for Enrollment in Medicare Part B Instructions
This form contains 48 fields organized into 11 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Additional Information | ||
| Remarks | Text |
Provide any additional information, explanations, or comments relevant to your Medicare Part B enrollment application.
|
| Contact Information | ||
| Mailing Address | Text |
Enter your mailing address, including number and street, PO Box, or route.
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| City | Text |
Enter the city for your mailing address.
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| State | Text |
Enter the two-letter U.S. state abbreviation for your mailing address.
|
| Zip Code | Text |
Enter the five-digit ZIP code for your mailing address.
|
| Phone Area Code | Text |
Enter the three-digit area code of your telephone number.
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| Phone Prefix | Text |
Enter the three-digit prefix (central office code) of your telephone number.
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| Phone Line Number | Text |
Enter the four-digit line number of your telephone number.
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| Coverage History | ||
| Employer Coverage Start Year | Text |
Enter the year (YYYY) you or your spouse began working for the employer that provided health coverage. Fill only if the 'Do you currently have (or did you have) coverage through an employer or union group health plan?' is 'Yes'.
|
| Employer Coverage End Month | Text |
Enter the month (MM) your employment with the employer that provided health coverage ended. Fill only if the 'Do you currently have (or did you have) coverage through an employer or union group health plan?' is 'Yes'.
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| Employer Coverage End Year | Text |
Enter the year (YYYY) your employment with the employer that provided health coverage ended. Fill only if the 'Do you currently have (or did you have) coverage through an employer or union group health plan?' is 'Yes'.
|
| Employer coverage – Not ended | CheckBox |
Check this box if your (or your spouse’s) employment with an employer that provided health coverage has not ended. Fill only if the 'Do you currently have (or did you have) coverage through an employer or union group health plan?' is Yes.
|
| Non-Profit Organization Coverage Start Month | Text |
Enter the month (MM) you began health coverage from a non-profit organization employer. Fill only if the 'Are you currently (or were you) an international volunteer for a non-profit organization and have or had health coverage provided to you?' is 'Yes'.
|
| Non-Profit Organization Coverage Start Year | Text |
Enter the year (YYYY) you began health coverage from a non-profit organization employer. Fill only if the 'Are you currently (or were you) an international volunteer for a non-profit organization and have or had health coverage provided to you?' is 'Yes'.
|
| Non-Profit Organization Coverage End Month | Text |
Enter the month (MM) your health coverage from a non-profit organization employer ended. Fill only if the 'Are you currently (or were you) an international volunteer for a non-profit organization and have or had health coverage provided to you?' is 'Yes'.
|
| Non-Profit Organization Coverage End Year | Text |
Enter the year (YYYY) your health coverage from a non-profit organization employer ended. Fill only if the 'Are you currently (or were you) an international volunteer for a non-profit organization and have or had health coverage provided to you?' is 'Yes'.
|
| Health coverage (employer or non-profit) – Not ended | CheckBox |
Check this box if the period of health coverage from your employer (or non-profit organization) has not ended.
|
| Volunteer Outside U.S. Start Month | Text |
Enter the month (MM) you started volunteer work outside the U.S. Fill only if the 'Are you currently (or were you) an international volunteer for a non-profit organization and have or had health coverage provided to you?' is 'Yes'.
|
| Volunteer Outside U.S. Start Year | Text |
Enter the year (YYYY) you started volunteer work outside the U.S. Fill only if the 'Are you currently (or were you) an international volunteer for a non-profit organization and have or had health coverage provided to you?' is 'Yes'.
|
| Volunteer Outside U.S. End Month | Text |
Enter the month (MM) your volunteer work outside the U.S. ended. Fill only if the 'Are you currently (or were you) an international volunteer for a non-profit organization and have or had health coverage provided to you?' is 'Yes'.
|
| Volunteer Outside U.S. End Year | Text |
Enter the year (YYYY) your volunteer work outside the U.S. ended. Fill only if the 'Are you currently (or were you) an international volunteer for a non-profit organization and have or had health coverage provided to you?' is 'Yes'.
|
| Volunteer coverage – Not ended | CheckBox |
Check this box if your volunteer work outside the U.S. and its associated health coverage period has not ended. Fill only if the 'Are you currently (or were you) an international volunteer for a non-profit organization and have or had health coverage provided to you?' is Yes.
|
| Eligibility | ||
| Requested or required to enroll in Part B – Yes | CheckBox |
Check this box if an employer, health insurance provider, or other entity requested or required you to enroll in Part B.
|
| Requested or required to enroll in Part B – No | CheckBox |
Check this box if no employer, health insurance provider, or other entity requested or required you to enroll in Part B.
|
| Enrollment Information | ||
| Sign up for Medicare Part B (Medical Insurance) – Yes | CheckBox |
Check this box if you want to sign up for Medicare Part B (Medical Insurance).
|
| Coverage through employer or union group health plan – Yes | CheckBox |
Check this box if you currently have or previously had coverage through an employer or union group health plan.
|
| Coverage through employer or union group health plan – No | CheckBox |
Check this box if you do not currently have and have not had coverage through an employer or union group health plan.
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| International volunteer non-profit organization health coverage – Yes | CheckBox |
Check this box if you are currently or were an international volunteer for a non-profit organization and have or had health coverage provided to you.
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| International volunteer non-profit organization health coverage – No | CheckBox |
Check this box if you are not currently or were not an international volunteer for a non-profit organization with health coverage provided to you.
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| Employer Coverage Start Date | Date |
Enter the month and year (MM/YYYY) when you or your spouse began working for the employer that provided health coverage. Fill only if the 'Employer or union group health plan coverage' is 'Yes'.
|
| Personal Information | ||
| Medicare Number Segment 1 | Text |
Enter the first segment of your Medicare number exactly as it appears on your Medicare card.
|
| Medicare Number Segment 2 | Text |
Enter the second segment of your Medicare number exactly as it appears on your Medicare card.
|
| Medicare Number Segment 3 | Text |
Enter the third segment of your Medicare number exactly as it appears on your Medicare card.
|
| Last Name | Text |
Enter your last name (surname) exactly as it appears on your Medicare card or legal documents.
|
| First Name | Text |
Enter your first name (given name) exactly as it appears on your Medicare card or legal documents.
|
| Middle Name | Text |
Enter your middle name or initial exactly as it appears on your Medicare card; leave blank if none.
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| Signature | ||
| 10 Written Signature DO NOT PRINT SIGN HERE | Signature |
Sign your name here. Do not print your name.
|
| Signature Date | ||
| Date Signed Month | Text |
Enter the month (MM) when the applicant signed the form.
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| Date Signed Day | Text |
Enter the day (DD) when the applicant signed the form.
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| Date Signed Year | Text |
Enter the year (YYYY) when the applicant signed the form.
|
| Witness Address | ||
| Witness Street Number and Name | Text |
Enter the witness’s street number and street name for their address.
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| Witness City | Text |
Enter the city where the witness resides.
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| Witness State | Text |
Enter the two-letter U.S. state abbreviation for the witness’s address.
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| Witness ZIP Code | Text |
Enter the five-digit ZIP Code for the witness’s address.
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| Witness Information | ||
| 12.Signature of Witness | Signature |
Provide the signature of the witness who is verifying the information on the form.
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| Witness Signature Date | ||
| Witness Signature Date - Month | Text |
Enter the month the witness signed the application as a two-digit number.
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| Witness Signature Date - Day | Text |
Enter the day the witness signed the application as a two-digit number.
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| Witness Signature Date - Year | Text |
Enter the year the witness signed the application as a four-digit number.
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