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Application medicare part b form

Omb no 0938 1230-2026

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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 to the local Social Security office and details about potential penalties for late enrollment.

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Click ‘Get Form’ to open the OMB No. 0938-1230 application 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 if available.
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; do not print your name. If unable to sign, mark an 'X' and ensure a witness completes their information.
Record the date you signed the application in the appropriate section.
If applicable, have a witness sign and provide their details as required.

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medicare part b form

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