Forms & Resources

 If you are already enrolled in Medicare Part A and would like to enroll in Part B, you must complete this Application for Enrollment in Medicare – Part B (Medical Insurance).

Download form: https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/CMS-Forms-Items/CMS017339

Complete form online: CMS-40B

If you are applying for Medicare Part B due to a loss of employment or group health coverage, you will also need to complete a Request for Employment Information.

CMS-L564: https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS-L564E.pdf

Complete form online: CMS-L564

You can also sign up online by going to the Medicare Sign Up page, and scrolling to the middle of page. 

https://www.ssa.gov/medicare/sign-up

You can also fax the Employer Verification form to 1-833-914-2016; or return forms by mail or in person to your local Social Security office.   When completing the forms:

• State, “I want Part B coverage to begin (MM/YY)” in the remarks section of the CMS-40B form or online application.
• If your employer is unable to complete Section B, please complete that portion as best you can on behalf of your employer without your employer’s signature.
• Submit one of the following types of secondary evidence by uploading it from a saved document on your computer:
• Income tax returns that show health insurance premiums paid.
• W-2s reflecting pre-tax medical contributions.
• Pay stubs that reflect health insurance premium deductions.
• Health insurance cards with a policy effective date.
• Explanations of benefits paid by the GHP or LGHP.
• Statements or receipts that reflect payment of health insurance premiums.

Sign up online (scroll to middle of page). https://www.ssa.gov/medicare/sign-up

You should complete this application for Extra Help if:

• You have Medicare Part A (Hospital Insurance) and/or Medicare Part B (Medical Insurance); and
• You live in one of the 50 States or the District of Columbia; and
• Your combined savings, investments, and real estate are not worth more than $35,130, if you are married and living with your spouse, or $17,600 if you are not currently married or not living with your spouse. (Do NOT count your home, vehicles, personal possessions, life insurance, burial plots, irrevocable burial contracts or back payments from Social Security or SSI.) If you have more than those amounts, you may not qualify for the Extra Help program. However, you can still enroll in an approved Medicare prescription drug plan for coverage.
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EXCEPTION: Even if you meet these conditions, DO NOT complete this application if you have Medicare and Supplemental Security Income (SSI) or Medicare and Medicaid because you automatically will get the extra help.

https://www.medicare.gov/basics/costs/help/drug-costs

https://www.ssa.gov/medicare/part-d-extra-help