Since you did not enroll in Part B when you enrolled in Part A, you will have to submit documentation to show you had creditable coverage from your 65th birthday or your Part A start date (whichever is earlier). You will need the Request for Employment Information to apply for Part B.
- Send this to your employer first for completion. See more information below about completing this form.
- Once you receive the completed copy back from your employer, you can apply for Part B.
You will need your completed (and signed by HR) Request for Employment Information Form in front of you for the application because you will need to key in all of the fields completed on this form.
Go to “Apply Online for Medicare Part B During a Special Enrollment Period” and complete online form.
- In the notes/comments section please write: “I would like my Medicare Part B to begin ___/01/202__.”
- At the end of the application you will upload your evidence of Group Health Plan or Large Group Health Plan by clicking the “click to attach Employment Verification” button in the form.
After you digitally sign the application, you will receive an email asking you to confirm your digital signature. YOUR SIGNATURE IS NOT COMPLETE AND YOUR APPLICATION WILL NOT BE PROCESSED UNTIL YOU COMPLETE THE INSTRUCTIONS IN YOUR EMAIL. If you do not receive an email within a few minutes, please check your Junk folder
We strongly advise that you keep your email confirmation receipt and to continuously check your www.myssa.gov to check on the processing. If you do not see Medicare Part B populate in your www.ssa.gov/myaccount account prior to your effective date request, please contact your Social Security office to confirm that they are in receipt of your application.
Complete forms CMS-40B (Part B Application) and CMS-L564 (Request for Employment Information)
- In the notes/comments section of the Part B application please write: “I would like my Medicare Part B to begin ___/01/202___.”
Fax your forms to your local Social Security field office (look up local fax and phone number with this link)
We strongly advise that you call the local Social Security Field Office 3 days after faxing to confirm receipt
Complete forms CMS-40B (Part B Application) and CMS-L564 (Request for Employment Information)
- In the notes/comments section of the Part B application please write: “I would like my Medicare Part B to begin ___/01/202___.”
Mail your forms to your local Social Security field office (look up address with this link)
We do not recommend this option if you are within 30 days of your requested effective date. If you do not receive confirmation of your application processing prior to your requested effective date, please contact your local Social Security field office to confirm that they are in receipt of your application.
Currently many Social Security Offices are not accepting in person visits.
Check with your local Social Security field office (look up local fax and phone number with this link)
Complete forms CMS-40B (Part B Application) and CMS-L564 (Request for Employment Information)
- In the notes/comments section of the Part B application please write: “I would like my Medicare Part B to begin ___/01/202___.”
More information on the Request For Employment Information
This form is necessary to show you have a valid enrollment period and to avoid a Medicare Part B late enrollment penalty.
- Please take this form to the Human Resources Department to complete.
- You will need a form completed for each spouse that wishes to apply for Medicare.
- The form confirms you have had creditable coverage since you turned age 65, which will show that you are eligible for enrollment; as well as, waive a late enrollment penalty.
Creditable coverage is verified on the form by:
- The dates the Employee was Actively Employed.
- The date you were covered under the Group Health Plan.
- The start date should reflect the initial enrollment in group coverage NOT the date of your last enrollment period.
If you have not been covered under the same employer since you turned age 65, you will need an Employment Verification Form from each employer that provided you group coverage.
- If your employer is out of business or unable to sign this form, other acceptable verifying documents may be accepted. Contact HTA if you need a list of other acceptable types of documentation.