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form 40b application

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I want part B coverage to begin. Other I want to enroll in part B only. TO Form HCFA-40B PRIVACY ACT NOTICE The Social Security Administration SSA is authorized to collect information on this form under sections 1836 1840 and 1872 of the Social Security Act as amended 42 U.S.C. APPLICATION FOR ENROLLMENT IN MEDICARE THE MEDICAL INSURANCE PROGRAM SOCIAL SECURITY CLAIM NUMBER/BIC beneficiary identification code DO YOU WISH TO ENROLL FOR MEDICAL INSURANCE UNDER MEDICARE YES Part B Only CLAIMANT...
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Who needs the HCFA-40B form?

The HCFA-40B form is the Application for Enrollment in Medicare that should be completed by individuals who are eligible for this federal health insurance program but haven’t been enrolled automatically. The medicare program is created for individuals who have reached the age of 65 or are older, younger persons who have permanent disabilities and End-Stage Renal Disease (ESD) — a permanent kidney failure requiring dialysis or a transplant.

What is the purpose of the Medicare Enrollment Application form?

The information indicated on the HCFA-40B form will be used by the Social Security Administration (SSA) and the Health Care Financing Administration (CFA) to establish if the applicant is entitled to supplementary medical insurance benefits.                

When is the Medicare Enrollment Application due?

The HCFA-40B Enrollment Application can be used during the initial enrollment period (which lasts for seven months beginning with the third month prior to the month when the applicant reaches the age of 65, or it can start 3 months before the 25th month after the applicant became eligible for the SSA disability benefits.

If the applicant didn’t manage to file the Medicare Enrollment Application, it can be also submitted during the general enrollment period, which starts at the beginning of each year and lasts for three months.

Is the HCFA-40B accompanied by any other forms?

No, there is no need to attach any other forms to the filled out Application for Enrollment in Medicare.

How to fill out the form HCFA-40B?

The following questions must be covered to properly fill out the application form:

  • Social Security claim number;

  • Name of the claimant;

  • Name of the SSN holder;

  • Mailing address;

  • Date of completion;

  • Signature;

  • Signature and address of the witness if appropriate;

  • Remarks;

  • Destination.

Where to send the completed HCFA form 40B?

The filled out Medicare Enrollment Application form must be submitted through the local SSA office.

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