Crosswalk

Revisions to Form CMS 4040 (OMB 0938-0245) Request for Enrollment in Medicare Part B (Medical Insurance)
The form was updated to add the optional collection of email addresses. In response to SSA technician’s feedback, the form now
includes a question that allows the applicant to select a Medicare start date. CMS’ Office of Communications provided feedback on
the form design and the layout of the questions. The form was redesigned to give the applicant’s a more user friendly experience. No
additional changes were made and the burden was not impacted by the changes.
Changes
Updated Form

Original Form

Reason for Change

Title: Request for
Enrollment in Medicare
Part B (Medical
Insurance)
Instructions page

Title: Request for
Enrollment in
Supplementary Medical
Insurance
Instructions page

OC plain language suggestion

Burden
Effect
N/A

Updated to plain language.

N/A

Condensed form and
removed the step-bystep instructions. The
instructions are now
included with the
questions instead of on
a separate page.

Questions numbered
without having a
specific section or
category.

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•
•

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Updated formatting to
match Medicare brand &
style
Updated language to
align with Medicare.gov
program info
Linked to Medicare.gov
for program details so
info is current &
comprehensive
Added SHIPs resource
language to the “Get
help” section
Removed field numbers
unless used for

N/A

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•

navigation (i.e. “go to
item 4”)
Standardized field labels
across forms
Standardized the
“witness” section across
forms