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The document explains eligibility timing, including Initial Enrollment Period (IEP), General Enrollment Period (GEP) from January 1–March 31, and Special Enrollment Period (SEP) based on group health plan coverage. It lists required information, such as the Medicare number, contact details, and CMS-L564 when applicable, and provides submission and help contacts, plus reminders about premiums and late enrollment penalties.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/application-for-enrollment-in-medicare-part-b-medical-insurance-cms-40b-form/306130/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/application-for-enrollment-in-medicare-part-b-medical-insurance-cms-40b-form/306130.png","ImageObject",442,249,{"name":88,"@type":89},"Fez","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-11","2026-09-19",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",8,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"Who can use this Medicare Part B application?","Question",{"text":109,"@type":110},"People with Medicare who have Part A but not Part B can use the form. 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Send the completed and signed application to your local Social Security office and include CMS-L564 with your Part B application if applicable.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},306130,1790207989,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":79,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":73},2336478940794,"https://ap-avatar.wpscdn.com/davatar_9964176cb1d06d4a9deccf72a44ae3dc","DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES  \nForm Approved OMB No. 0938-1230 Expires: 02/20  \nAPPLICATION FOR ENROLLMENT IN MEDICARE PART B (MEDICAL INSURANCE)  \nWHO CAN USE THIS APPLICATION?  \nPeople with Medicare who have Part A but not Part B NOTE: If you do not have Part A, do not complete this form. Contact Social Security if you want to apply for Medicare for the first time.  \nWHEN DO YOU USE THIS APPLICATION? Use this form:  \n• If you’re in your Initial Enrollment Period (IEP) and live in Puerto Rico. You must sign up for Part B using this form.  \n• If you’re in your IEP and refused Part B or did not sign up when you applied for Medicare, but now want Part B.  \n• If you want to sign up for Part B during the General Enrollment Period (GEP) from January 1 – March 31 each year.  \n• If you refused Part B during your IEP because you had group health plan (GHP) coverage through your or your spouse’s current employment. You may sign up during your 8-month Special Enrollment Period (SEP) .  \n• If you have Medicare due to disability and refused Part B during your IEP because you had group health plan coverage through your, your spouse or family member’s current employment.  \n• You may sign up during your 8-month SEP.  \nNOTE: Your IEP lasts for 7 months. It begins 3 months before your 65th birthday (or 25th month of disability) and ends 3 months after you reach 65 (or 3 months after the 25th month of disability) .  \nWHAT INFORMATION DO YOU NEED TO COMPLETE THIS APPLICATION?  \nYou will need:  \n• Your Medicare Number  \n• Your current address and phone number  \n• Form CMS-L564 ”Request for Employment Information”completed by your employer if you’re signing up in a SEP.  \nWHAT HAPPENS NEXT?  \nSend 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. TTY users should call 1-800-325-0778.  \nHOW DO YOU GET HELP WITH THIS  \nAPPLICATION?  \n• Phone: Call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778.  \n• En español: Llame a SSA gratis al 1-800-772-1213 y oprima el 2 si desea el servicio en español y espere a que leatienda un agente.  \n• In person: Your local Social Security office. For an office near you [check](check www.ssa.gov)[ ](check www.ssa.gov)[www.ssa.gov](check www.ssa.gov).  \nREMINDERS  \n• If you sign up for Part B, you must pay premiums for every month you have the coverage.  \n• If you sign up after your IEP, you may have to pay a late enrollment penalty (LEP) of 10% for each full 12-month period you don’t have Part B but were eligible to sign up.  \nYou have the right to get Medicare information in an accessible format, like large print, Braille, or audio. You also have the right to file a complaint if you feel you’ve been discriminated against. Visit [https://www.medicare.gov/about-us/accessibility](https://www.medicare.gov/about-us/accessibility)nondiscrimination-notice, or call 1-800-MEDICARE (1-800-633-4227) for more information. TTY users  \ncan call 1-877-486-2048.  \nCMS-40B (04/19) 1  \nDEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES  \nForm Approved OMB No. 0938-1230 Expires: 02/20  \n\n| APPLICATION FOR ENROLLMENT IN MEDICARE PART B (MEDICAL INSURANCE) |\n| --- |\n| 1. Your Medicare Number |\n| 2. Do you wish to sign up for Medicare Part B (Medical Insurance)?  YES |\n\n3. Your Name (Last Name, First Name, Middle Name)  \n4. Mailing Address (Number and Street, P.O. Box, or Route)  \n5. City State Zip Code  \n6. Phone Number (including area code)  \n(  )  –   \n\n| 7. Written Signature (DO NOT PRINT)\u003Cbr>SIGN HERE | 8. Date Signed |  |  |  |  | / |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n|  |  |  | / |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |  |\n\nIF THIS APPLICATION HAS BEEN SIGNED BY MARK (X), A WITNESS WHO KNOWS TH","cbCaissKGSyDNo8F","https://ap.wps.com/l/cbCaissKGSyDNo8F","pdf",67539,"English","# WHO CAN USE THIS APPLICATION?\n# WHEN DO YOU USE THIS APPLICATION?\n# WHAT INFORMATION DO YOU NEED TO COMPLETE THIS APPLICATION?\n# WHAT HAPPENS NEXT?\n# HOW DO YOU GET HELP WITH THIS APPLICATION?\n# REMINDERS","[{\"question\":\"Who can use this Medicare Part B application?\",\"answer\":\"People with Medicare who have Part A but not Part B can use the form. If you do not have Part A, the instructions say not to complete the form and to contact Social Security instead.\"},{\"question\":\"When can I use this application to sign up for Part B?\",\"answer\":\"Use it during your Initial Enrollment Period (IEP) or during the General Enrollment Period (GEP) from January 1–March 31. It can also be used during an eligible Special Enrollment Period (SEP) related to group health plan coverage through current employment.\"},{\"question\":\"What information is required to complete and submit the application?\",\"answer\":\"You need your Medicare number, current address and phone number, and (if signing up in a SEP) a Form CMS-L564 completed by your employer. Send the completed and signed application to your local Social Security office and include CMS-L564 with your Part B application if applicable.\"}]","APPLICATION FOR ENROLLMENT IN MEDICARE PART B (MEDICAL INSURANCE) - CMS-40B - Form | PDF",1789833108]