Form CMS-4040: Request for Enrollment in Medicare Part B (Medical Insurance)

Use this form to enroll in Medicare Part B if you’re NOT entitled to Social Security/Railroad Retirement Board benefits. Submit your completed and signed form by mail, fax, or by visiting your local Social Security office in person. Find an office near you at SSA.gov/locator. Contact Social Security at 1-800-772-1213 (TTY 1-800-325-0778) with questions.