Part A and B Enrollment Forms (Downloads Below)

CMS-18-F-5: Individuals who do not have Part A and wish to enroll should complete the CMS-18-F-5 form or contact Social Security at 1-800-772-1213. This form can be used to enroll in Part B at the same time. If applying for the SEP for the Working aged and Working Disabled, also complete the form CMS-L564.

CMS-40B : Individuals who have Part A, but not Part B, should complete form CMS-40B to enroll in Part B. If applying for the SEP for the Working aged and Working Disabled, also complete the form CMS-L564.

CMS-4040: Individuals who are NOT entitled to social security or railroad retirement board benefits should complete form CMS-4040 to enroll in Part B.

CMS-43: Individuals who have ESRD should complete form CMS-43 to enroll in Part A and Part B.

CMS-10797: Individuals who qualify for a special enrollment period due to exceptional conditions should complete the CMS-10797 to enroll in premium Part A and Part B.

CMS-L564: Individuals who are applying for the SEP for the Working Aged and Working Disabled should complete the form CMS-L564 along with the applicable Part A or Part B enrollment form.