Application for Enrollment in Medicare - Part B (Medical Insurance)
O.M.B. Expiration Date
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. 1-800-772-1213; TTY: 1-800-325-0778