Important Forms for Enrolling in Medicare

Sign up for Part B- Click Here English Spanish If you already have Medicare Part A (Hospital Insurance) and you’re eligible to enroll in Medicare Part B (Medical Insurance) through a Special Enrollment Period (SEP), you have options for how to apply. You can apply online or you can mail your completed CMS 40B, Application for Enrollment in Medicare – Part B (Medical Insurance) to your local Social Security office. You’ll also need to send CMS L564 – Request for Employment Information, and a required proof of employment, Group Health Plan (GHP), or Large Group Health Plan (LGHP) coverage with your 40B form.

Form L564-REQUEST FOR EMPLOYMENT INFORMATION- click here- English Spanish

If you have Medicare Part A (Hospital Insurance) and you’re eligible to enroll in Medicare Part B (Medical Insurance) through a Special Enrollment Period (SEP), you have options for how to apply. You can complete the Part B SEP online or you can mail your completed CMS 40B, Application for Enrollment in Medicare – Part B (Medical Insurance) and CMS L564 – Request for Employment Information to your local Social Security office. You’ll also need to send any required proof of employment, Group Health Plan (GHP), or Large Group Health Plan (LGHP) coverage.

APPLICATION FOR MEDICARE PART A AND PART B – SPECIAL ENROLLMENT PERIOD (EXCEPTIONAL CONDITIONS)- Click Here English Spanish

WHAT IS THE PURPOSE OF THIS FORM? If, due to an exceptional condition, you didn’t sign up for Medicare Premium Part A or Part B during your Initial Enrollment Period (IEP), General Enrollment Period (GEP), or a Special Enrollment Period (SEP) you were previously eligible for, you can sign up without a late enrollment penalty during a SEP for Exceptional Conditions. If you think that you may be eligible for a SEP for Exceptional Conditions, please contact Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. NOTE: Your IEP lasts for 7 months. It begins 3 months before your 65th birthday (or 25th month of disability) and ends 3 months after you reach 65 (or 3 months after the 25th month of disability). The GEP is from January 1 – March 31 each year. The most common SEPs apply to the working aged, disabled, and international volunteers. WHAT INFORMATION DO YOU NEED TO COMPLETE THIS

Social Security and your retirement plan Social Security is part of the retirement plan of almost every American worker. It’s important to know how the system works and how much you’ll receive from us when you retire. This booklet explains: • How you qualify for Social Security benefits. • How your earnings and age can affect your benefits. • What you should consider in deciding when to retire. • Why you shouldn’t rely only on Social Security for all your retirement income. This basic information about Social Security retirement benefits isn’t intended to answer all questions. For specific information about your situation, you should talk with one of our representatives. Please call our toll-free number.