Document text
Medicare Sign-Up Checklist
Name: [FULL NAME]
Date of birth: [DATE OF BIRTH]
Filled in on: [DATE]
1. My dates
What My date
Month I turn 65 [MONTH AND YEAR]
My Initial Enrollment Period starts, 3 months before that month [MONTH AND YEAR]
It ends, 3 months after that month [MONTH AND YEAR]
Date my work stopped, if I had job-based coverage [DATE]
8 months after that date [DATE]
2. How I sign up
Mark one My situation What I do
☐ I already get Social Security or Railroad Retirement Board benefits I should be signed up automatically. I watch for my card
☐ I do not get those benefits yet I apply through Social Security: online, or at my local office
☐ I have Part A and want Part B I send form CMS-40B
☐ I am still working, or retired or lost job coverage in the last 8 months I send CMS-40B and CMS-L564 together
3. What I have ready
Done Item
☐ My Social Security account, if I apply online
☐ CMS-40B, filled in
☐ CMS-L564, completed with my employer
☐ The date I sent everything: [DATE]
4. Open Enrollment, October 15 to December 7
For changing plans. The plan must get my request by December 7, and coverage starts January 1.
Compare Plan 1 Plan 2 Plan 3
Plan name [NAME] [NAME] [NAME]
Monthly premium $[AMOUNT] $[AMOUNT] $[AMOUNT]
Deductible $[AMOUNT] $[AMOUNT] $[AMOUNT]
My drugs covered [YES OR NO] [YES OR NO] [YES OR NO]
My doctors included [YES OR NO] [YES OR NO] [YES OR NO]