Real-world examples of Medicare enrollment form examples (and how to fill them out)

Start with real examples, not definitions

Most people don’t want a lecture on Medicare rules. They want to see examples of Medicare enrollment form examples that look like their own situation. So let’s start with real stories and the exact forms those people would use.

We’ll walk through:

• Someone turning 65 and signing up for Medicare for the first time
• Someone who kept working past 65 and now needs Part B later
• Someone who wants to sign up for a Medicare Advantage plan
• Someone adding or changing a Part D drug plan
• Someone correcting a mistake on a form
• Someone helping a family member who can’t sign for themselves

As we go, notice how each example of a situation connects to a specific form, like CMS-40B, CMS-L564, or a Medicare Advantage enrollment form.

Example of enrolling in Medicare Part B at 65 (CMS-40B)

Imagine Maria, who turns 65 in June 2025. She’s already getting Social Security retirement benefits, so she’ll be enrolled in Medicare Part A automatically. But she also wants Part B so doctor visits and outpatient care are covered.

This is where one of the most common examples of Medicare enrollment form examples comes in: Form CMS-40B (Application for Enrollment in Medicare Part B).

Here’s what that looks like in real life:

• Maria receives a notice from Social Security about her upcoming Medicare eligibility.
• She sees that Part A will start automatically, but she still needs to confirm Part B.
• She uses CMS-40B to request Part B coverage to start the month she turns 65.

On a filled-out example of the CMS-40B form, you’d typically see:

• Section 1 – Personal Information: Her name exactly as it appears on her Social Security card, date of birth, and Social Security number.
• Section 2 – Enrollment Request: She checks the box to sign up for Part B and selects the month she wants coverage to begin (usually her 65th birthday month, or the first day of that month).
• Signature and Date: She signs and dates the form, acknowledging she understands the monthly premium.

In 2024–2025, many people use their online Medicare account instead of mailing this form, but the questions and information are effectively the same as in this paper example.

For official instructions and the latest version of CMS-40B, Social Security posts it here: https://www.ssa.gov/forms/.

Examples of Medicare enrollment form examples when you retire after 65 (CMS-40B + CMS-L564)

Now let’s look at one of the best examples of a slightly more complicated situation: working past 65.

Meet David. He’s 68, has had employer health coverage through his job, and delayed Medicare Part B because his employer plan was primary. In 2025, he decides to retire.

David needs:

• Form CMS-40B to enroll in Part B
• Form CMS-L564 (Request for Employment Information) to prove he had qualifying coverage and avoid a late enrollment penalty

Here’s how a realistic example of this combo looks:

How David fills out CMS-40B

Similar to Maria, David:

• Enters his personal information
• Checks the box to sign up for Part B
• Requests his Part B coverage to start the month after his employer coverage ends

How David and his employer complete CMS-L564

This is where many people get stuck, so it’s helpful to see how examples of Medicare enrollment form examples handle it.

On a typical completed CMS-L564:

• Section A (To be completed by the individual): David fills in his name, Social Security number, and signs.
• Section B (To be completed by the employer): His HR department fills in:
  • The dates he had group health plan coverage
  • Whether the coverage was based on current employment
  • The size of the employer (important for Medicare rules)

This form confirms that David had creditable coverage, which protects him from a Part B late enrollment penalty. Many 2024–2025 retirees rely on this exact pairing of forms, making it one of the most common real examples of Medicare enrollment form examples you’ll see.

Medicare provides details on Special Enrollment Periods and these forms here: https://www.medicare.gov/sign-up-change-plans.

Example of signing up for a Medicare Advantage plan (MA enrollment form)

Now let’s shift to someone choosing a Medicare Advantage plan (Part C).

Picture Linda, age 70, who already has Original Medicare (Parts A and B). In fall 2024, during the Medicare Open Enrollment Period (October 15 to December 7), she decides she wants a Medicare Advantage plan that includes drug coverage and a $0 premium.

Linda uses a Medicare Advantage plan enrollment form, usually provided by the private insurance company. While the layout varies by company, the examples include the same core elements:

• Personal information: name, address, phone, Medicare number
• Medicare coverage: checking boxes to show she has Part A and Part B
• Plan selection: the specific Medicare Advantage plan name and ID
• Primary care provider: sometimes she must select a doctor within the network
• Payment options: how she wants any plan premiums paid (for example, deducted from her Social Security check)

A realistic example of this form would show Linda:

• Confirming her current Medicare coverage
• Attesting she understands she is switching from Original Medicare to a Medicare Advantage plan
• Signing to allow the plan to access her Medicare information

These plan-specific forms are some of the most common examples of Medicare enrollment form examples used every fall. The rules for these plans and enrollment periods are explained on Medicare.gov: https://www.medicare.gov/plan-compare.

Example of enrolling in a Part D drug plan (stand-alone PDP form)

Next, consider Sam. He has Original Medicare and a Medigap policy but no prescription drug coverage. After a new diabetes diagnosis in 2025, his doctor prescribes several medications that are getting expensive.

Sam decides to join a stand-alone Part D Prescription Drug Plan (PDP). He uses the plan’s Part D enrollment form, which is similar in structure to the Medicare Advantage form but focused on drug coverage.

In a typical filled-out example of a Part D form, you’d see:

• Sam’s Medicare number and proof that he has Part A and/or Part B
• The specific drug plan he’s choosing
• A section asking about other drug coverage (like VA benefits or employer plans)
• Signature confirming he understands late enrollment penalties may apply

The best examples of these forms help people compare costs, formularies, and pharmacies before they sign. Medicare’s plan finder is often used alongside these forms: https://www.medicare.gov/drug-coverage-part-d/how-to-get-prescription-drug-coverage.

Examples of Medicare enrollment form examples for Special Enrollment Periods

Life doesn’t always line up neatly with open enrollment dates. That’s where Special Enrollment Periods (SEPs) come in, and they often require specific forms.

Here are two realistic SEP scenarios that generate very specific examples of Medicare enrollment form examples:

Moving out of your plan’s service area

Jordan has a Medicare Advantage plan in Texas. In 2025, he moves permanently to Colorado. Because his old plan doesn’t operate in his new area, he qualifies for a Special Enrollment Period.

In practice, you’d see:

• A Medicare Advantage disenrollment or change form, often provided by the new plan in Colorado
• Jordan confirming his move date and new address
• Enrollment in a new Medicare Advantage or Part D plan that serves his new ZIP code

Losing employer or union coverage mid-year

Tanya, age 67, has retiree coverage through her former employer. In mid-2024, the employer discontinues the retiree plan. Tanya now has a Special Enrollment Period to join Part D or a Medicare Advantage plan.

In real examples, she may use:

• A Part D or Medicare Advantage enrollment form with a section asking why she qualifies for a SEP
• Documentation from her former employer showing the loss of coverage date

These SEP-related forms are some of the most time-sensitive examples of Medicare enrollment form examples, because missing deadlines can lead to gaps in coverage or penalties.

Example of correcting a mistake on a Medicare enrollment form

Mistakes happen. Maybe you checked the wrong box, picked the wrong start date, or realized you mis-typed your Medicare number.

Let’s say Paul accidentally signed up for a Medicare Advantage plan he didn’t want during the Annual Enrollment Period. Within the Medicare Advantage Open Enrollment Period (January 1–March 31), he can switch back to Original Medicare or to a different Medicare Advantage plan.

In reality, you’d see:

• A new Medicare Advantage enrollment form for the plan he actually wants
• Or, a disenrollment request if he’s going back to Original Medicare

There isn’t always a single dedicated “correction form.” Instead, the best examples show that you usually submit a new form that overrides the old one, as long as you’re still within a valid enrollment window.

For official details on these timeframes, see Medicare’s enrollment period guide: https://www.medicare.gov/basics/get-started-with-medicare/when-does-medicare-coverage-start.

Example of appointing someone to help with Medicare decisions (CMS-1696)

Sometimes the most important paperwork isn’t about your own signature at all.

Consider Evelyn, who has early dementia. Her daughter, Carla, helps with medical decisions and wants to talk directly with Medicare and plan representatives.

They use Form CMS-1696 (Appointment of Representative). This form doesn’t enroll you, but it’s often used alongside other examples of Medicare enrollment form examples when someone can’t manage the process alone.

A realistic filled-out example of CMS-1696 would show:

• Evelyn’s information as the beneficiary
• Carla’s information as the appointed representative
• A description of the issues Carla is authorized to handle (for example, enrollment appeals or plan changes)
• Signatures from both Evelyn and Carla (or documentation of legal authority if Evelyn can’t sign)

Medicare explains representation and this form here: https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms.

How 2024–2025 trends affect Medicare enrollment forms

Forms may look old-school, but the way people submit them is changing fast.

Some key 2024–2025 trends that show up across many examples of Medicare enrollment form examples:

• More online enrollment: Many people now enroll in Medicare or change plans through their online Social Security account or directly on plan websites. The questions mirror the paper forms, but the process is faster and often flags missing information.
• Electronic signatures: Insurance companies increasingly accept e-signatures for Medicare Advantage and Part D enrollment forms, reducing mailing delays.
• Real-time eligibility checks: When you submit a form online, the system often checks your Medicare eligibility instantly, catching errors that would have taken weeks to surface with paper.
• Clearer language and notices: After years of complaints about confusing language, some newer form versions and online workflows use plainer English, especially around late enrollment penalties and coverage start dates.

Even with these updates, the core information you see in our examples of Medicare enrollment form examples hasn’t changed much: name, Medicare number, coverage choices, and signatures are still the backbone of every application.

FAQ: Common questions about Medicare enrollment form examples

Q: Where can I see official examples of Medicare enrollment form examples?
You can view official blank forms like CMS-40B, CMS-L564, and CMS-1696 on Social Security’s and CMS’s websites. While they don’t always show filled-out samples, the instructions often walk through example scenarios:

• Social Security forms: https://www.ssa.gov/forms/
• CMS Medicare forms: https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms

Q: Can I submit Medicare enrollment forms online instead of using paper?
Often, yes. Many people enroll in Medicare Parts A and B using their my Social Security account, and most Medicare Advantage and Part D plans allow online enrollment. The online questions mirror the paper forms, so the same examples of situations apply.

Q: What is an example of a situation where I should use CMS-L564?
A classic example is someone who delayed Part B because they had employer coverage and is now retiring. They submit CMS-40B to enroll in Part B and CMS-L564, completed by their employer, to prove they had creditable coverage and avoid a late enrollment penalty.

Q: Do I need a separate form for Medicare Supplement (Medigap) policies?
Yes. Medigap policies are offered by private insurers, and each company has its own application. These are different from Medicare Advantage and Part D forms, but they ask similar questions about your existing Medicare coverage and health history.

Q: What if I send in a Medicare enrollment form with a mistake?
In many cases, you can correct the error by contacting Social Security, Medicare, or the plan directly and submitting updated information or a new enrollment form. The best practice is to fix it as soon as you notice it, especially if you’re close to the end of an enrollment period.

If you remember nothing else, remember this: every confusing Medicare situation usually has a form that matches it. Once you see a few real examples of Medicare enrollment form examples tied to real people and timelines, the whole system starts to feel a lot less intimidating.