Dynamic List Information
Dynamic List Data
Form #
CMS 4040
Form Title
Request for Enrollment in Medicare Part B (Medical Insurance)
Revision Date
2025-07-01
O.M.B. #
0938-0245
O.M.B. Expiration Date
2028-07-31
Special Instructions
Use this form to enroll in Medicare Part B if you’re NOT entitled to Social Security/Railroad Retirement Board benefits. Submit your completed and signed form by mail, fax, or by visiting your local Social Security office in person. Find an office near you at SSA.gov/locator. Contact Social Security at 1-800-772-1213 (TTY 1-800-325-0778) with questions.