Application for Enrollment in Medicare - Part B (Medical Insurance)
O.M.B. Expiration Date
Return the completed forms to your local Social Security office by mail or fax it to 1-833-914-2016. If you do not have Medicare Part A –Hospital Insurance (HI), please complete an application online or contact your local Social Security office to enroll. There is no charge for Part A benefits. If you have questions call Social Security’s toll-free number 1-800-772-1213 (TTY 1-800-325-0778). Get answers to frequently asked questions at faq.ssa.gov. NOTE: If you are eligible to enroll under the Special Enrollment Period and unable to mail your CMS 40-B, Application for Enrollment in Medicare - Part B (Medical Insurance) along with the CMS L564- Request for Employment Information, and proof of employment, Group Health Plan (GHP), or Large Group Health Plan (LGHP), fax them to 1-833-914-2016. Your employer does not need to sign Part B of the CMS L564 form.