Form Approved 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 Centers for Medicare & Medicaid 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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Versions	Form popularity	Fillable & printable
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)

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

How long does it take for Medicare Part B to be approved?

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.

Can I stop Medicare Part B without penalty?

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).

Can you stop and restart Medicare Part B?

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.

Can I opt out of Medicare Part B at any time?

You can cancel Part A only if you pay a premium for it. You can cancel Part B at any time.

Is there a penalty for cancelling Medicare Part B?

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.