CMS 40-B Telephonic Attestation
During this interview, we will ask you questions that will be used to process [your/or name of claimant's] Application for Enrollment in Medicare - Part B (Medical Insurance), CMS Form 40B, for Medicare Part B. At the end of the interview, we will ask you to confirm the truthfulness of your answers under penalty of perjury and we will record your response. You should be aware that you can be held legally responsible for giving us false information.
You will receive a notice stating changes to your benefits to retain for your records. Do you understand that you must review all of this information carefully and let us know right away if anything needs to be corrected OR if any of the information changes?
Do you understand that the information you have provided will be used to process [your/or name of claimant's] Application for Enrollment in Medicare - Part B (Medical Insurance), CMS Form 40B? Do you declare under penalty of perjury that this information is true and correct to the best of your knowledge?
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Patterson, Carla (CMS/CM) |
| File Modified | 0000-00-00 |
| File Created | 2025-05-19 |