Printable Medicare Part B Forms You lost job based health coverage within the last 8 months To sign up for Part B in one of these situations you ll also need to fill out and submit an Application for Enrollment in Part B CMS 40B form at the same time Sign up for Part A Part B using a Special Enrollment Period
Get the forms you need to sign up for Part B Medical Insurance Get Enrollment Forms Appeals forms Get forms to appeal a Medicare coverage or payment decision Get Appeals Forms Other forms Get forms to file a claim set up recurring premium payments and more Find Medicare gov on facebook link opens in a new tab Follow Medicare gov on Set up an appointment Available in most U S time zones Monday Friday 8 a m 7 p m in English and other languages Call 1 800 772 1213 Tell the representative you need help with enrolling in Part B during the Special or General Enrollment Period Call TTY 1 800 325 0778 if you re deaf or hard of hearing
Printable Medicare Part B Forms
Printable Medicare Part B Forms
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A federal government website managed and paid for by the U S Centers for Medicare and Medicaid Services 7500 Security Boulevard Baltimore MD 21244 Interactive Form Tips Select Highlight fields and or Highlight required fields to ensure all form fields are completed To view field instructions including CMS supplied instructions when provided hover over desired field Blank and completed forms may be saved to a user s computer Right click PDF hyperlink and select Save as
This form is your application for Medicare Part B Medical Insurance You can use this form to sign up for Part B During your Initial Enrollment Period IEP when you re first eligible for Medicare During the General Enrollment Period GEP from January 1 through March 31 of each year If you re eligible for a Special Enrollment Period CMS 40B 04 17 b3 fForm Approved OMB No 0938 1230 Expires XX XX STEP BY STEP INSTRUCTIONS FOR FILLING OUT THIS APPLICATION 1 Your Medicare Number Write your Medicare number 6 Phone Number Write your 10 digit phone number including area code 2
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You can complete form CMS 40B Application for Enrollment in Medicare Part B Medical Insurance and CMS L564 Request for Employment Information online You can also fax the CMS 40B and CMS L564 to 1 833 914 2016 or return forms by mail to your local Social Security office Please contact Social Security at 1 800 772 1213 TTY 1 800 Part A hospital insurance Part A helps pay for inpatient care at Hospitals Skilled nursing facilities Hospice It also covers some outpatient home health care Part A is free if you worked and paid Medicare taxes for at least 10 years You may also be eligible because of your current or former spouse s work
Medicare Part A Reimbursement Medicare Part A covers inpatient hospital services equipment medications and tests This inpatient portion of Medicare also covers a limited amount of time in a skilled nursing facility after a hospital stay as well as hospice care and home healthcare Typically your doctors will bill Medicare directly You have until March 31 2024 to sign up for Part B Your Part B coverage will start the first day of the month after you sign up To sign up fill out the enclosed form Be sure to Check the YES box and sign the application Write in your Medicare Number that s printed on your Medicare card
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https://www.medicare.gov/basics/forms-publications-mailings/forms/enrollment
You lost job based health coverage within the last 8 months To sign up for Part B in one of these situations you ll also need to fill out and submit an Application for Enrollment in Part B CMS 40B form at the same time Sign up for Part A Part B using a Special Enrollment Period
https://www.medicare.gov/basics/forms-publications-mailings/forms
Get the forms you need to sign up for Part B Medical Insurance Get Enrollment Forms Appeals forms Get forms to appeal a Medicare coverage or payment decision Get Appeals Forms Other forms Get forms to file a claim set up recurring premium payments and more Find Medicare gov on facebook link opens in a new tab Follow Medicare gov on
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Printable Medicare Part B Forms - Interactive Form Tips Select Highlight fields and or Highlight required fields to ensure all form fields are completed To view field instructions including CMS supplied instructions when provided hover over desired field Blank and completed forms may be saved to a user s computer Right click PDF hyperlink and select Save as
