Get Cms 4040 Form

Filling out the Cms 4040 Form online is an essential step for individuals looking to enroll in Medicare's supplementary medical insurance. This guide provides clear and detailed instructions to assist you in completing the form accurately.

Follow the steps to fill out your Cms 4040 Form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by printing your name clearly in the designated area. If your name at birth is different, make sure to enter that in the next field.
3. Provide your date of birth in the format of month, day, and year, and enter the name of the state or foreign country where you were born.
4. Select your sex by checking the appropriate box.
5. If applicable, answer questions regarding the existence of a public or religious record of your birth.
6. Indicate whether you have previously enrolled for supplementary medical insurance under Medicare.
7. If you or your spouse receive a monthly annuity under applicable laws, complete the corresponding fields with the necessary information.
8. Answer citizenship and residency questions; if you are not a U.S. citizen, you will need to provide additional details.
9. List your addresses for the last five years, starting with your most recent residence.
10. Review information related to premium payments associated with your enrollment.
11. Affirm the accuracy of your information by signing the form, providing your date of signature, and entering your contact details.
12. If you signed the application with a mark, ensure two witnesses provide their signatures and addresses.
13. Once you have completed the form, save your changes, download a copy, print it, or share the form as needed.

Start completing your Cms 4040 Form online today to ensure a smooth enrollment process.