If you need to apply for Medicare Part B, contact us for a free consultation.
The two downloads below are printable forms to enroll in Medicare Part B.
These 2 documents need to be completed in order to enroll in Medicare Part B.
WHAT IS THE PURPOSE OF THIS FORM?
In order to apply for Medicare in a Special Enrollment Period, you must have or had group health plan coverage within the last 8 months through your or your spouse’s current employment. People with disabilities must have large group health plan coverage based on your, your spouse’s or a family member’s current employment. This form is used for proof of group health care coverage based on current employment. This information is needed to process your Medicare enrollment application. The employer that provides the group health plan coverage completes the information about your health care coverage and dates of employment.
HOW IS THE FORM COMPLETED?
Complete the first section of the form so that the employer can find and complete the information about your coverage and the employment of the person through which you have that health coverage. The employer fills in the information in the second section and signs at the bottom.
WHAT DO I DO WITH THE FORM?
Fill out Section A and take the form to your employer. Ask your employer to fill out Section B. You need to get the completed form from your employer and include it with your Application for Enrollment in Medicare (CMS-40B). Then you send both together to your local Social Security office. Find your local office here: www.ssa.gov.
You and your employer need to complete this document. This will prove you have had health insurance since you turned 65.
If you already have Medicare Part A but need to enroll in Medicare Part B:
For example, if you’re leaving an employer plan.
This attachment is for people over 65 and still enrolled in employer sponsored plans. This form needs to be completed by the employer and submitted to Medicare with the Part B enrollment form.
WHO CAN USE THIS APPLICATION?
People with Medicare who have Part A but not Part B. If you do not have Part A, do not complete this form. Contact Social Security to apply for Medicare for the 1st time.
WHEN DO YOU USE THIS APPLICATION?
• If you’re in your Initial Enrollment Period (IEP) and live in Puerto Rico. You must sign up for Part B using this form.
• If you’re in your IEP and refused Part B or did not sign up when you applied for Medicare, but now want Part B.
• If you want to sign up for Part B during the General Enrollment Period (GEP) from January 1 – March 31 each year.
• If you refused Part B during your IEP because you had group health plan (GHP) coverage through your or your spouse’s current employment. You may sign up during your 8-month Special Enrollment Period (SEP).
• If you have Medicare due to disability and refused Part B during your IEP because you had group health plan coverage through your, your spouse or family member’s current employment.
• You may sign up during your 8-month SEP.
NOTE: Your IEP lasts for 7 months. It begins 3 months before your 65th birthday (or 25th month of disability) and ends 3 months after you reach 65 (or 3 months after the 25th
month of disability).
WHAT INFORMATION DO YOU NEED TO COMPLETE THIS APPLICATION?
• Your Medicare Number
• Your current address and phone number
• Form CMS-L564 ”Request for Employment Information” completed by your employer if you’re signing up in a SEP.
WHAT HAPPENS NEXT?
Send your completed and signed application to your local Social Security office. If you sign up in a SEP, include the CMS-L564 with your Part B application.
REMINDERS
• If you sign up for Part B, you must pay premiums for every month you have the coverage.
• If you sign up after your IEP, you may have to pay a late enrollment penalty (LEP) of 10% for each full 12-month period you don’t have Part B but were eligible to sign up.
All Social Security offices are still closed due to the pandemic.
You’ll need to call Social Security to get the correct fax number for you.
Call Social Security at 1-800-772-1213
Here’s how to look up the number to your local office: Type in your zip code at this link and give them the phone number: https://secure.ssa.gov/ICON/main.jsp