Form Approved OMB No 0938-1230-2025

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Initial Enrollment Period (IEP) The 7-month period when someone is first eligible for Medicare. For those eligible due to age, this period begins 3 months before they turn 65, includes the month they turn 65, and ends 3 months after they turn 65. Coverage begins the month after a person signs up during their IEP.
Fill out the Application for Enrollment in Medicare Part B (CMS-40B) (PDF). If you are applying during the Special Enrollment Period, also fill out the Request for Employment Information (CMS-L564) (PDF).
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.
You can cancel Part A only if you pay a premium for it. You can cancel Part B at any time.
What is the penalty if I cancel Part B without qualifying health coverage? If you drop Part B without having creditable health coverage, you might face a monthly late enrollment penalty. This penalty is 10% of the Part B premium for each 12-month period you didnt have Part B or eligible job-based insurance.