Use the Form CMS-40B (Application for Medicare Part B (Medical Insurance)) for D-SEP
enrollment requests. For retroactive supplementary medical insurance (SMI) elections,
indicate in the remarks section the date the beneficiary wants SMI coverage to begin.
Annotate “DISABILITY SEP” prominently at the top of the enrollment request.
Forward a copy of the employer letter, the carrier certification and any necessary
clarifying documentation along with the enrollment request to the processing center
(PC). For information about the employer and carrier documentation, see HI 00805.300B.2. Include a Form SSA-5002 (Report of Contact) that lists the months excluded from the
premium surcharge calculation.