Cms40b 2017 form-2026

The document is an application form for enrollment in Medicare Part B (Medical Insurance) provided by the Department of Health and Human Services. It outlines who can use the application, the process for signing up during different enrollment periods (Initial Enrollment Period, General Enrollment Period, and Special Enrollment Period), and the necessary information required to complete the application. It also includes instructions for submitting the form and contact information for assistance.

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Click ‘Get Form’ to open the cms40b 2017 form in the editor.
Enter your Social Security Claim Number and Beneficiary Identification Code (BIC) in the designated fields.
Indicate whether you wish to sign up for Medicare Part B by marking 'YES' if applicable.
Fill in your name as it appears on your Social Security records, including last name, first name, and middle name.
Provide your complete mailing address, including street number, P.O. Box, city, state, and ZIP code.
Input your phone number with area code in the specified field.
Sign the application in the signature field; if unable to sign, mark an 'X' and ensure a witness completes their information.
Date your signature appropriately in the provided section.
If applicable, have a witness sign and provide their details as required.
Review all entries for accuracy before submitting your completed application to your local Social Security office.

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Versions	Form popularity	Fillable & printable
2024	4.5 Satisfied (31 Votes)
2023	4.4 Satisfied (24 Votes)
2021	4.8 Satisfied (113 Votes)
2019	4.1 Satisfied (70 Votes)
2018	4.3 Satisfied (204 Votes)
2017	4.1 Satisfied (58 Votes)
1990	4.3 Satisfied (43 Votes)