CMS 18F5

This application is for people age 65 and older (or turning 65 within 3 months) who want to apply for Medicare Part A hospital coverage. Submit your completed and signed form by mail, fax, or by visiting your local Social Security office in person. For questions or assistance, call Social Security at 1-800-772-1213 (TTY 1-800-325-0778) or visit SSA.gov/locator to find your local office.