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You can complete the Part B SEP online or you can mail your completed CMS 40B, Application for Enrollment in Medicare - Part B (Medical Insurance) and CMS L564 - Request for Employment Information to your local Social Security office.
Get the forms you need to sign up for Part B including CMS-40B, CMS-L564, CMS-10797, and CMS-10798.
This form is your application for Medicare Part B (Medical Insurance). You can use this form to sign up for Part B: During your Initial Enrollment Period (IEP) when you’re first eligible for Medicare. During the General Enrollment Period (GEP) from January 1 through March 31 of each year.
Fill out the Application for Enrollment in Medicare Part B (CMS-40B) (PDF). If you are applying during the Special Enrollment Period, also fill out the Request for Employment Information (CMS-L564) (PDF).
If you prefer, you can fax or mail the completed forms – CMS-40B Application for Enrollment in Medicare – Part B (Medical Insurance) and CMS-L564 Request for Employment Information – to your local Social Security office. Be sure to carefully read the instructions on the forms.
Go to “Apply Online for Medicare Part B During a Special Enrollment Period” and complete CMS-40B and CMS-L564. Then, upload your evidence of Group Health Plan (GHP) or Large Group Health Plan (LGHP) coverage based on current employment.