en-USDEPARTMENT OF HEALTH AND HUMAN SERVICESen-USCENTERS FOR MEDICARE & MEDICAID SERVICES en-USAPPLICATION FOR ENROLLMENT IN MEDICARE PART B (MEDICAL INSURANCE)en-USWHO CAN USE THIS APPLICATION?en-USPeople with Medicare who have Part A but not Part Ben-USNOTE: en-USIf you do en-USnoten-US have Part A, do en-USnoten-US complete this form. en-USContact Social Security if you want to apply for Medicare for en-USthe first time.en-USWHEN DO YOU USE THIS APPLICATION?en-USUse this form: 225 en-USIf you222re in your en-USInitial Enrollment Perioden-US (IEP) and live inen-USPuerto Ricoen-US. You must sign up for Part B using this form. 225 en-USIf you222re in your en-USIEPen-US and en-USrefused Part B en-USor did not sign upen-USwhen you applied for Medicare, but now want Part B. 225 If you want to sign up for Part B during the General en-USEnrollment Period (GEP) from January 1 226 March 31 en-USeach year. 225 en-USIf you refused Part B during your IEP because you haden-USgroup health plan (GHP) coverage through your or youren-USspouse222s current employment. You may sign up duringen-USyour 8-month Special Enrollment Period (SEP). 225 en-USIf you have Medicare due to disability and refused Parten-USB during your IEP because you had group health planen-UScoverage through your, your spouse or family member222sen-UScurrent employment. 225 en-USYou may sign up during your 8-month SEP.en-USNOTE: en-USYour IEP lasts for 7 months. It begins 3 months before en-USyour 65th birthday (or 25th month of disability) and ends en-US3 months after you reach 65 (or 3 months after the 25th en-USmonth of disability). en-USWHAT INFORMATION DO YOU NEED TO en-USCOMPLETE THIS APPLICATION?en-USYou will need: 225 en-USYour Medicare Number 225 en-USYour current address and phone number 225 en-USForm CMS-L564 224Request for Employment Information224en-UScompleted by your employer en-USif you222re signing up in a SEPen-US. en-USWHAT HAPPENS NEXT?en-USSend your completed and signed application to your local en-USSocial Security office. If you sign up in a SEP, include the en-USCMS-L564 with your Part B application. If you have questions, en-UScall Social Security at en-US1-800-772-1213en-US.en-US TTY users should call en-US1-800-325-0778.en-USHOW DO YOU GET HELP WITH THIS en-USAPPLICATION? 225 en-USPhone: en-USCall Social Security at en-US1-800-772-1213en-US. en-USTTY usersen-USshould call 1-800-325-0778. 225 en-USEn espa361ol: en-USLlame a SSA gratis al en-US1-800-772-1213en-US y oprimaen-USel 2 si desea el servicio en espa361ol y espere a que leen-USatienda un agente. 225 en-USIn person: en-USYour local Social Security office. For an officeen-USnear you check en-USwww.ssa.goven-US.en-USREMINDERS 225 en-USIf you sign up for Part B, you must pay premiums foren-USevery month you have the coverage. 225 en-USIf you sign up after your IEP, you may have to pay a lateen-USenrollment penalty (LEP) of 10% for each full 12-monthen-USperiod you don222t have Part B but were eligible to sign up. en-USYou have the right to get Medicare information in an accessible format, like arge rint, Braille, or udio. You also have the right to file a complaint if you feel you222ve been discriminated against. Visit https://www.medicare.gov/about-us/accessibility-nondiscrimination-notice, or call 1-800-MEDICARE (1-800-633-4227) for more information. TTY users can call 1-877-486-2048.en-USForm Approveden-USOMB No. 0938-1230en-USExpires: 02/20en-USCMS-40B (04/1) 1 American LegalNet, Inc. www.FormsWorkFlow.com DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICES APPLICATION FOR ENROLLMENT IN MEDICARE PART B (MEDICAL INSURANCE)1.Your Medicare Number2.Do you wish to sign up for Medicare Part B (Medical Insurance)? YES3.Your Name (Last Name, First Name, Middle Name)4.Mailing Address (Number and Street, P.O. Box, or Route)5.CityStateZip Code6.Phone Number (including area code) ( ) 226 7.Written Signature (DO NOT PRINT)SIGN HERE8.Date Signed / / IF THIS APPLICATION HAS BEEN SIGNED BY MARK (X), A WITNESS WHO KNOWS THE APPLICANT MUST SUPPLY THE INFORMATION REQUESTED BELOW.9.Signature of Witness10.Date Signed / / 11.Address of Witness12.RemarksAccording to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1230. The time required to complete this information is estimated to average 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850. CMS-40B (04/1) 2 Form ApprovedOMB No. 0938-1230Expires: 02/20 American LegalNet, Inc. www.FormsWorkFlow.com SPECIAL MESSAGE FOR INDIVIDUAL APPLYING FOR PART BThis form is your application for Medicare Part B (Medical Insurance). You can use this form to sign up for Part B: 225During your Initial Enrollment Period (IEP) when you222refirst eligible for Medicare225During the General Enrollment Period (GEP) fromJanuary 1 through March 31 of each year225If you222re eligible for a Special Enrollment Period (SEP),like if you222re covered under a group health plan (GHP)based on current employment.Initial Enrollment PeriodYour IEP is the first chance you have to sign up for Part B. It lasts for 7 months. It begins 3 months before the month you reach 65, and it ends 3 months after you reach 65. If you have Medicare due to disability, your IEP begins 3 months before the 25th month of getting Social Security Disability benefits, and it ends 3 months after the 25th month of getting Social Security Disability benefits. To have Part B coverage start the month you222re 65 (or the 25th month of disability insurance benefits); you must sign up in the first 3 months of your IEP. If you sign up in any of the remaining 4 months, your Part B coverage will start later.General Enrollment PeriodIf you don222t sign up for Part B during your IEP, you can sign up during the GEP. The GEP runs from January 1 through March 31 of each year. If you sign up during a GEP, your Part B coverage begins July 1 of that year. You may have to pay a late enrollment penalty if you sign up during the GEP. The cost of your Part B premium will go up 10% for each 12-month period that you could have had Part B but didn222tsign up. You may have to pay this late enrollment penalty aslong as you have Part B coverage.Special Enrollment PeriodIf you don222t sign up for Part B during your IEP, you can sign up without a late enrollment penalty during a Special Enrollment Period (SEP). If you think that you may be eligible for a SEP, please contact Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778 You can use a SEP when your IEP has ended. The most common SEPs apply to the working aged, disabled, and international volunteers.Working Aged/DisabledYou have a SEP if you222re covered under a group health plan (GHP) based on current employment. To use this SEP, you must:225Be 65 or older and currently employed225Be the spouse of an employed person, and covered underyour spouse222s employer GHP based on his/her currentemployment225Be under 65 and disabled, and covered under a GHPbased on your own or your spouse222s current employmentYou can sign up for Part B anytime while you have a GHP coverage based on current employment or during the 8 months after either the coverage ends or the employment ends, whichever happens first. If you sign up while you have GHP coverage based on current employment, or, during the first full month that you no longer have this coverage, your Part B coverage will begin the first day of the month you sign up. You can also choose to have your coverage begin with any of the following 3 months. If you sign up during any of the remaining 7 months of your SEP, your Part B coverage will begin the month after you sign up. NOTE: COBRA coverage or a retiree health pla