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If you have Medicare Part A (Hospital Insurance) and you’re eligible to enroll in Medicare Part B (Medical Insurance) through a Special Enrollment Period (SEP), you have options for how to apply.
CMS - L564. DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. Form Approved. OMB No. 0938-0787 Expires: 10/2024. WHAT IS THE PURPOSE OF THIS FORM?
Request for Employment Information (CMS-L564) What’s it used for? Giving the Social Security Administration proof you’re eligible to sign up for Part B if: You’re still working. You retired within the last 8 months. You lost job-based health coverage within the last 8 months.
You can complete your Medicare Part B Enrollment online. You will electronically sign the online application, so you will need to provide an email address. If you prefer, you can fax or mail the completed forms – CMS-40B Application for Enrollment in Medicare – Part B (Medical Insurance) and CMS-L564 Request for Employment Information ...
Fill out the Application for Enrollment in Medicare Part B (CMS-40B) (PDF). If you are applying during the Special Enrollment Period, also fill out the Request for Employment Information (CMS-L564) (PDF).
What Is Medicare Form CMS-L564? Form CMS-L564 is a form used by the Social Security Administration to grant a Special Enrollment Period to Medicare beneficiaries who initially turned down Part B coverage because they were receiving group health benefits from their employer or a spouse’s employer.
Go to “Apply Online for Medicare Part B During a Special Enrollment Period” and complete CMS-40B and CMS-L564. Then, upload your evidence of Group Health Plan (GHP) or Large Group Health Plan (LGHP) coverage based on current employment.
The CMS-L564 is called a request for employment information. You are responsible to fill out Section A of this form with your employer’s name and address. The purpose of this form is to verify that you’ve been employed and had employer coverage from the time you turned 65 to enrollment in Medicare.
Social Security Form CMS-L564 verifies your group health plan coverage so you can apply to enroll in Medicare part B during a special enrollment period...
what is the purpose of this form? In order to apply for Medicare in a Special Enrollment Period, you must have or had group health plan coverage within the last 8 months through your or your spouse’s current employment.