Track Change

Form Approved
OMB No. 0938-0245
Expires: 10/24

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

REQUEST FOR ENROLLMENT IN SUPPLEMENTARY MEDICAL INSURANCE
WHO CAN USE THIS APPLICATION?
People who wish to enroll in Medicare Part B.

local Social Security office. If you have questions, call
Social Security at 1-800-772-1213. TTY users should call
1-800-325-0778.

WHEN DO YOU USE THIS APPLICATION?
USE THIS FORM IF:

HOW DO YOU GET HELP WITH THIS APPLICATION?

You wish to enroll in Medicare Part B, but you are NOT
entitled to Social Security/Rail Road Retirement
Board benefits.

• Phone: Call Social Security at 1-800-772-1213. TTY
users should call 1-800-325-0778.

WHAT INFORMATION DO YOU NEED TO COMPLETE
THIS APPLICATION?
YOU WILL NEED:

• En español: Llame a SSA gratis al 1-800-772-1213 y
oprima el 2 si desea el servicio en español y espere a que
le atienda un agente.
• In person: Your local Social Security office. For an
office near you check www.ssa.gov.

• Your Social Security Number
• Date of Birth
• Your current address and phone number
• Work History

WHAT HAPPENS NEXT?
Send your completed and signed application to your

REMINDERS
• If you sign up for Part B, you must pay premiums for
every month you have the coverage.
• If you sign up after your IEP, you may have to pay a
late enrollment penalty (LEP) of 10% for each full
12-month period you don’t have Part B but were eligible
to sign up.

SPECIAL MESSAGE FOR INDIVIDUAL APPLYING FOR MEDICARE
This form is your application for Medicare Part B (Medical Insurance). You can use this form to sign up:
• During your Initial Enrollment Period (IEP) when you’re first eligible for Medicare.
INITIAL ENROLLMENT PERIOD
Your IEP is the first chance you have to sign up for Part B. It lasts for 7 months. It begins 3 months before
the month you reach 65, and it ends 3 months after you reach 65. If you have Medicare due to
disability, your IEP begins 3 months before the 25th month of getting Social Security Disability
• Contributing to your HSA 6 months before applying for Medicare in order to not be penalized by the IRS.
For more information about HSA penalties, visit https://www.irs.gov.

You have the right to get Medicare information in an accessible format, like large print, Braille, or audio. You also have the right to file a
complaint if you feel you’ve been discriminated against. Visit https://www.medicare.gov/about-us/accessibility-nondiscrimination-notice, or call
1-800-MEDICARE (1-800-633-4227) for more information. TTY users can call 1-877-486-2048.
Form CMS-4040 (09/23)

1

REQUEST FOR ENROLLMENT IN SUPPLEMENTARY MEDICAL INSURANCE
1. Print Your Name: (Last Name, First Name, Middle Name)

2. Sex - Select One
Male

Female

4. Date of Birth: (MM/DD/YYYY)

3. Social Security Number:

___-__-____

4a. State or Country of Birth

5. Have you ever before enrolled in
Medicare Part B?

1a. If your name at birth was different, please enter your name at birth.

4b. Record of Birth

6. Do you or your spouse receive a mothly annuity under the Federal Civil Service Retirement Act, or other
law administered by the office of Personnel Management?

Yes
No
Unknown
Yes
No If yes, please provide
6a. If yes, provide the civil service annuity number for you or your
6b. If you provided your spouse’s number, is he or she enrolled in
spouse.
7. Are you a resident of the United States? This means that you’ve
made your home in the United States. Select One:
Yes
No
9. Are you lawfully admitted for permanent residence in
the United States? Select One:

8. Are you a US Citizen? Select One:
Yes

No

Yes
No
10. Write the address for your places of residence in the last 5 years starting with your current address. Use remarks section if you
need more space.
Date Residence Began: MM/DD/YYYY

a.
b.
c.
11. Remarks

12. Written Signature

13. Date Signed

/
14. Address of Witness

14a City, State, Zip

15. Signature of Witness

15a. Date Signed

15b. Address of Witness

Form CMS-4040 (09/23)

/

Date Residence Ended: MM/DD/YYYY

STEP BY STEP INSTRUCTIONS
1. Name: Write your name as you did when you applied
for Social Security or Medicare. List last name, first name
and middle name in that order. If you don’t have a
middle name, leave it blank.

8. Are you a United States Citizen? Select: YES or NO.

1a. If your name at birth was different, please enter your
name at birth.

10. Write the address for your places of residence in
the last 5 years starting with your current address. Use
remarks section if you need more space.

2. Sex: Select One: Male or Female
3. Your Social Security Number: Write your 9 digit social
security number.
4. Date of Birth: Write your date of birth (MM/DD/YYYY).
4a. State or Country of Birth: Write the name of the
state or foreign country in which you were born
(NO abbreviations).
4b. Record of Birth: If a public record of your birth was
made before you were age 5 (i.e. birth certificate) you
must submit proof. If you do not have a public record
of your birth before age 5, submit a religious record of
your birth before age 5, if applicable. If neither is known,
select unknown.
5. Have you ever before enrolled in Medicare Part B?
Select YES, NO, or UNKNOWN
6. Do you or your spouse receive a mothly annuity under
the Federal Civil Service Retirement Act, or other law
administered by the office of Personnel Management?
Select YES or NO. If YES, provide
6a. If yes, provide the civil service annuity number for
you or your spouse.
6b. If you provided your spouse’s number, is he or she
enrolled in

9. Are you lawfully admitted for permanent residence in
the United States? Select One: YES or NO.

11.Remarks: Write any remarks that you have regarding
your application.
12. Written Signature: Sign your name in this section in
the same way you would sign it for any other official
document. Do not print. If you’re unable to sign, you
may mark an “X” in this field. In this case, you will need
a witness and the witness must complete question 23.
13. Date Signed: Write the date that you signed the
application.
14. Mailing Address: Write the house number and street
address of your current residence
14a. City, State, Zip code, country: Write the city, state,
zipcode and country of your current residence
15. Signature of Witness:In the case that question 21
is signed by an “X” instead of a written signature, a
witness signature is needed in question 23 showing
that the person who signs the application is the person
represented on the application.
15a. Date Signed: If a witness signs this application, the
witness must provide the date of the signature.
15b. Address of Witness: If a witness signs this
application, provide the witness’s address.

7. Are you a resident of the United States? This means
that you’ve made your home in the United States.
Select One: YES or NO

PRIVACY ACT STATEMENT: Social Security is authorized to collect your information under sections 1836, 1840, and 1872 of the Social Security Act,
as amended (42 U.S.C. 1395o, 1395s, and 1395ii) for your enrollment in Medicare Part B. Social Security and the Centers for Medicare & Medicaid
Services (CMS) need your information to determine if you’re entitled to Part B. While you don’t have to give your information, failure to give all or
part of the information requested on this form could delay your application for enrollment. Social Security and CMS will use your information to
enroll you in Part B. Your information may be also be used to administer Social Security or CMS programs or other programs that coordinate with
Social Security or CMS and in accordance with System of Records Notice (SORN) “HHS/CMS/CBC Enrollment Database”, System No. 09-70-0502, 73
Federal Register 10249, February 26th, 2008 and as permitted by the Privacy Act of 1974, to: 1) Determine your rights to Social Security benefits and/
or Medicare coverage. 2) Comply with Federal laws requiring Social Security and CMS records (like to the Government Accountability Office and the
Veterans Administration) 3) Assist with research and audit activities necessary to protect integrity and improve Social Security and CMS programs
(like to the Bureau of the Census and contractors of Social Security and CMS). We may verify your information using computer matches that help
administer Social Security and CMS programs in accordance with the Computer Matching and Privacy Protection Act of 1988 (P.L. 100-503).
PRA DISCLOSURE STATEMENT: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0245. The time
required to complete this information collection is estimated to average 10 minutes per response, including the time to review instructions,
search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning
the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports
Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Please do not send applications, claims, payments, medical records or
any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to
the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded,
or retained. If you have questions or concerns regarding where to submit your documents, please contact the Social Security Administration at
1-800-772-1213. TTY users can call 1-800-325-0778.

Form CMS-4040 (09/23)