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Form #
CMS 40B
Form Title
Application for Enrollment in Medicare - Part B (Medical Insurance)
Revision Date
2014-04-21
O.M.B. #
0938-1230
O.M.B. Expiration Date
2017-04-30
CMS Manual
N/A
Special Instructions
Return the completed form to your local Social Security Office. If you do not have Medicare Part A, you must contact the Social Security Administration in order to enroll. If you have questions or need assistance with enrolling, please visit or contact Social Security. 1-800-722-1213; TTY: 1-800-325-0778