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cms-40b fillable

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cms-40b fillable

PDF download:

application for enrollment in medicare part b – CMS

… you may have to pay a late enrollment penalty (LEP) of 10% for each full 12-
month period you don't have Part B but were eligible to sign up. CMS-40B (04/17)

Request for Employment Information – CMS

Application for Enrollment in Medicare (CMS-40B). Then you send both together
to your local Social Security office. Find your local office here:

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