40b form 2026

The document is an application form for enrollment in Medicare's medical insurance program, specifically for Part B coverage. It outlines the necessary personal information required from the applicant, including their Social Security number and mailing address. The form also provides details on enrollment periods, eligibility criteria, and potential penalties for late enrollment. Additionally, it includes a privacy notice regarding the use of the information provided.

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Click ‘Get Form’ to open the 40b form in the editor.
Begin by entering your Social Security Claim Number and BIC at the top of the form. This information is crucial for identification purposes.
Indicate whether you wish to enroll for medical insurance under Medicare by selecting 'YES – Part B Only'.
Fill in your name, including last name, first name, and middle initial. If applicable, print the Social Security number holder's name if it differs from yours.
Provide your mailing address, ensuring accuracy for correspondence. If this is a change of address, check the designated box.
Enter your telephone number in the specified format.
Sign and date the application where indicated. If a witness is required, ensure they complete their section as well.
Review all entries for accuracy before submitting your completed form to your local Social Security office.

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