Fill out CMS-L564 (Request for Employment Information) online
Form CMS-L564 provides proof to Social Security that an individual has been continuously covered by a group health plan based on current employment. It serves as documentation for Medicare Part B Special Enrollment Period (SEP) eligibility, proving that the applicant had employer-based coverage and is not subject to late enrollment penalties.
How to fill out CMS-L564 (Request for Employment Information)
Complete Section A (Individual Information)
Enter your name, date of birth, Medicare Beneficiary Identifier (MBI) or Social Security number, and the date you want Part B coverage to begin.
Forward the form to your employer
Give the form to your employer or former employer so they can complete Section B. The employer must verify your employment dates and group health plan coverage dates.
Employer completes Section B
The employer enters their company name, address, employer identification number (EIN), and confirms the dates of the employee's group health plan coverage. An authorized employer representative must sign and date this section.
Submit with CMS-40B
Once both sections are complete, submit the form along with Form CMS-40B to your local Social Security office. Keep copies of both forms for your records.
About CMS-L564 (Request for Employment Information)
Who needs this form
Medicare beneficiaries who delayed Part B enrollment because they had employer-sponsored group health coverage. The beneficiary completes Section A, and their employer (or former employer) completes Section B to verify the coverage dates.
Where to submit
Submit to your local Social Security Administration (SSA) office along with Form CMS-40B (the Part B enrollment application). Can be mailed or faxed to 1-833-914-2016.
Source and content freshness
- Filing deadlines may shift for weekends and holidays. Verify due dates with official instructions.
Common mistakes to avoid
- Not having the employer complete Section B (employer verification is required)
- Providing coverage dates that do not match the employer records
- Submitting CMS-L564 without CMS-40B (both forms are needed together)
- Not including the employer contact information for verification
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