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.

The easiest way to enroll is to visit www.ssa.gov/medicare.  Scroll Down to find the button for Apply for Medicare Only (or click here to go right to the application)

• In the notes/comments section please write: “I would like my Medicare Part B to be effective__/1/202__. I have completed a CMS-L564 (Request for Employment Information Form) signed by my employer.  I will fax this form along with my Part B application to my local social security office for processing.”
  • You should fax your Part B application and Request for Employment Information Form to your local social security office.  The fax number can be found by clicking on the link.
    • Where it asks for the Medicare Number write: applied online-pending
    • In the remarks box write: I would like my Part B to begin on __/1/202__

We strongly advise that you keep your email confirmation receipt and to continuously check your www.myssa.gov to check status on the processing.  If you not see Medicare Parts A&B populate in your www.myssa.gov account prior to your effective date request, please contact your Social Security office to confirm that they are in receipt of your application.

If you are applying for Medicare, but do not have 40 quarters of Medicare taxes due to your own history, you will have to apply under your spouses taxes and work history.

Under this circumstance, please contact your Social Security office to explain your situation and request enrollment in Medicare. 

• You may be asked for additional documentation such as your marriage certificate when you apply.