CMS-4040 Request for Enrollment in Supplementary Medical Insurance

Medicare Form Summary

In the case of the CMS-4040 form, Supplementary Medical Insurance refers to Medicare Part B. You’ll use this form if you are not eligible for automatic enrollment in Part B or you want to reenroll after terminating your coverage.

What you’ll need:
• Your name, sex, social security number, and date of birth
• To answer whether your spouse is enrolled in Part B
• To sign the form in ink

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