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Application medicare part b form

Omb no 0938 1230-2025

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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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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

Can I get a Medicare late enrollment penalty removed?

You can appeal to remove the penalty if you think you were continuously covered by Part B or job-based insurance. You can also appeal to lower the penalty amount if you think it was calculated incorrectly. Call your former employer or plan and ask for a letter proving that you were enrolled in coverage.

How do you get a Medicare Part B penalty waiver?

You may qualify to have your penalty waived if you were advised by an employee or agent of the federal government for example by Social Security or 1-800-MEDICARE to delay Part B. Asking for the correction is known as requesting equitable relief.

How do I get rid of part B late enrollment penalty?

Can Medicare Part B penalty be waived? If you dont qualify to delay Part B, youll need to enroll during your Initial Enrollment Period to avoid paying the penalty. You may refuse Part B without penalty if you have creditable coverage, but you have to do it before your coverage start date.

Can I cancel my Medicare Part B without penalty?

In most cases, you will have to pay that penalty every month for as long as you have Medicare. If you are enrolled in Medicare because of a disability and currently pay premium penalties, once you turn 65 you will no longer have to pay the premium penalty.

Can I fill out CMS 40B online?

You can apply online or you can mail your completed CMS 40B, Application for Enrollment in Medicare - Part B (Medical Insurance) to your local Social Security office.

medicare part b form

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Who is exempt from paying Medicare Part B premiums?

If you have Medicare Part A, but you did not enroll in Medicare Part B during your Initial Enrollment Period (IEP), you may sign up during the General Enrollment Period (GEP), or you may qualify for a Special Enrollment Period (SEP).