Form CMS-43: Application for Part A (Hospital Insurance) and Part B (Medical Insurance) for People with End-Stage Renal Disease

Complete this form to apply for Medicare if you End-Stage Renal Disease (ESRD), regardless of your age. Submit the completed and signed CMS-43 and CMS-2728 ESRD Medical Evidence Report completed by your healthcare provider 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.