Sign up for Medicare Part B Online, by Fax or Mail

You can complete form CMS-40B (Application for Enrollment in Medicare – Part B [Medical Insurance]) and CMS-L564 (Request for Employment Information) online.

You can also fax the CMS-40B and CMS-L564 to 1-833-914-2016; or return forms by mail to your local Social Security office. Please contact Social Security at 1-800-772-1213 (TTY 1-800-325-0778) if you have any questions.

Note: When completing the forms:

• State, “I want Part B coverage to begin (MM/YY)” in the remarks section of the CMS-40B form or online application.
• If your employer is unable to complete Section B, please complete that portion as best you can on behalf of your employer without your employer’s signature.
• Submit one of the following types of secondary evidence by uploading it from a saved document on your computer:
  • Income tax returns that show health insurance premiums paid.
  • W-2s reflecting pre-tax medical contributions.
  • Pay stubs that reflect health insurance premium deductions.
  • Health insurance cards with a policy effective date.
  • Explanations of benefits paid by the GHP or LGHP.
  • Statements or receipts that reflect payment of health insurance premiums.

  Please let your friends and loved ones know about this online, mail, or fax option.