Name and birth details
First, middle and last name and suffix, name as it appears on your birth certificate if different, sex, Social Security Number, date of birth (mm/dd/yyyy) and state or country of birth.
CMS-4040
Request for Enrollment in Medicare Part B (Medical Insurance)
- Agency
- CMS
- Revision
- 07/2025
- Fillable fields
- 65
- Pages
- 3
- Official source
- CMS form page
- Checked
- October 20, 2026
Form CMS-4040: Request for Enrollment in Medicare Part B (Medical Insurance)
Form CMS-4040 is the Request for Enrollment in Medicare Part B (Medical Insurance) from the Centers for Medicare & Medicaid Services, part of the U.S. Department of Health and Human Services. The form says it is for enrolling in Part B if you're NOT entitled to Social Security/Railroad Retirement Board benefits, and that it can be used during your Initial Enrollment Period when you're first eligible for Medicare. People entitled to those benefits are pointed to Form CMS-40B instead.
The form asks for your name, sex, Social Security Number, date and place of birth, phone and email, whether you were enrolled in Part B before, any civil service annuity, U.S. residence, citizenship and lawful presence, and the addresses where you lived for the last 5 years. It ends with your signature and mailing address.
The form says a record of birth is required, and that the signed form goes to your local Social Security office with it. You can fill it out free in your browser on this page and download the result without an account.
What's on Form CMS-4040
Record of birth note
The form says a record of birth is required: your original birth certificate, or a religious record of your birth made before age 5. It points to SSA.gov/help/iClaim_poa.html for more information.
Part B and annuity questions
Phone and email, whether you were ever enrolled in Part B (yes, no or unknown), and whether you or your spouse get a monthly annuity under the Federal Civil Service Retirement Act or another OPM law, with the CSA number if so.
Residence and status
Yes or no: whether you are currently a resident of the U.S., a U.S. citizen or U.S. national, and lawfully present in the U.S.
Address history and remarks
The addresses where you lived for the last 5 years with start and end dates (mm/dd/yyyy), and a Remarks section for more space.
Signature and mailing address
Signature and date signed, mailing address with city, state, ZIP code and country, and a witness block for a form signed by mark (X).
The form has an instructions page and two form pages.
How to submit Form CMS-4040
- 1
Check which form applies
The form is for people not entitled to Social Security/Railroad Retirement Board benefits. People entitled to them are pointed to Form CMS-40B.
- 2
Fill in your details
Enter your name, birth certificate name if different, sex, SSN, date and place of birth, phone and email.
- 3
Answer the questions
Answer the Part B history, civil service annuity, U.S. residence, citizenship and lawful presence questions.
- 4
List 5 years of addresses
List each address where you lived for the last 5 years with start and end dates. The form says to use Remarks if you need more space.
- 5
Sign and add your mailing address
Sign and date the form and enter your mailing address. A form signed by mark (X) also needs a witness's name, signature and date.
- 6
Send it with your birth record
Mail or fax the signed form and your birth record to your local Social Security office. The CMS page says it can also be submitted in person. Find an office at SSA.gov/locator.
Why fill Form CMS-4040 on indox
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
- Fill the form right in your browser, no software to install
- Free to fill and free to download, with no account
- The official blank straight from the CMS, not a copy someone retyped
- Works on a phone, tablet or computer
Where it goes, premiums and help
Where to send it
To your local Social Security office by mail or fax according to the form, or in person according to the CMS page. Find an office at SSA.gov/locator. The CMS address in the Paperwork Reduction Act notice is for comments on the form only.
Record of birth
The form says Social Security has to see the original document or copies certified by the agency that issued them, and that all documents are returned to you.
Premiums and late enrollment
The form says Part B premiums are paid for every month you have coverage. It says signing up after your Initial Enrollment Period may bring a late enrollment penalty of 10% for each full 12-month period you didn't have Part B but were eligible.
Health Savings Accounts
The form says that with a Health Savings Account (HSA), contributions stop 6 months before you apply for Medicare so you won't be penalized by the IRS, and points to IRS.gov.
Help with the form
Social Security: 1-800-772-1213, TTY 1-800-325-0778, with Spanish service by pressing 2. Free health insurance counseling is available from your State Health Insurance Assistance Program (SHIP) at shiphelp.org.
Other formats and time
Medicare information is available in large print, braille or audio at Medicare.gov/about-us/accessibility-nondiscrimination-notice or 1-800-MEDICARE (1-800-633-4227), TTY 1-877-486-2048. The form estimates an average of 10 minutes per response.
Related forms
CMS-40B
Request for Enrollment in Medicare Part B (Medical Insurance)
47 fields, 3 pages
CMS-18-F-5
Application for Medicare Part A (Hospital Insurance)
127 fields, 7 pages
CMS-43
Application for Part A (Hospital Insurance) and Part B (Medical Insurance) for People with End-Stage Renal Disease
155 fields, 6 pages
CMS-L564
Medicare Request for Employment Information
45 fields, 2 pages
CMS-10797
Application For Medicare Part A and Part B Special Enrollment Period (Exceptional Circumstances)
72 fields, 6 pages
CMS-1763
Request for Termination of Premium Hospital Insurance of Supplementary Medical Insurance
29 fields, 2 pages
Who uses Form CMS-4040?
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Questions about Form CMS-4040
Who can use Form CMS-4040?
The form says it is for enrolling in Medicare Part B if you're NOT entitled to Social Security/Railroad Retirement Board benefits, during your Initial Enrollment Period when you're first eligible for Medicare.
What if I'm entitled to Social Security benefits?
The form says to use Form CMS-40B, Request for Enrollment in Medicare Part B (Medical Insurance), instead. It is on CMS.gov, or call Social Security at 1-800-772-1213 for a copy.
Do I send a birth certificate with Form CMS-4040?
The form says a record of birth is required: an original birth certificate, or a religious record of your birth made before age 5. Social Security has to see the original or copies certified by the issuing agency, and returns all documents.
Where do I send Form CMS-4040?
The form says to mail or fax the completed, signed form and your birth record to your local Social Security office. The CMS page adds that you can visit the office in person. Find one at SSA.gov/locator.
When is the Initial Enrollment Period?
The form describes it as 7 months, beginning 3 months before the month you reach 65 and ending 3 months after. With Medicare due to disability, it begins 3 months before the 25th month of getting Social Security Disability.
Is there a penalty for signing up late?
The form says signing up after your Initial Enrollment Period may bring a late enrollment penalty of 10% for each full 12-month period you didn't have Part B but were eligible to sign up.
Who can I call about Form CMS-4040?
The form lists Social Security at 1-800-772-1213 (TTY 1-800-325-0778), in-person help at your local Social Security office, and your local SHIP at shiphelp.org for free counseling.