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You can complete the Part B SEP online or you can mail your completed CMS 40B, Application for Enrollment in Medicare - Part B (Medical Insurance) and CMS L564 - Request for Employment Information to your local Social Security office.
Form Approved OMB No. 0938-0787 Expires: 10/2024. REQUEST FOR EMPLOYMENT INFORMATION. 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. People with disabilities must have large
Get the forms you need to sign up for Part B including CMS-40B, CMS-L564, CMS-10797, and CMS-10798.
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).
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.
can complete and upload Form CMS-L564 (Request for Employment Information), or provide written notification (a letter, fax, or email) from the employer, GHP, or LGHP. 2. Fax your CMS-40B and employer-signed CMS-L564 (or written notification) to your local Social Security office. 3. Mail your CMS-40B and employer-signed CMS-L564
Have the employer fill out form CMS-L564. Send the completed form to your local Social Security office by fax or mail. If the employer can’t fill it out, complete Section B of the CMS-L564 form as best you can, but don’t sign it.
For those of you enrolling in Medicare when you’re first eligible at 65, you will not need to worry about filling out the forms. In fact, enrolling in Medicare when you turn 65 is a simple process that can be done entirely online. The CMS-L564 is called a request for employment information.
If you are applying for Medicare Part B due to a loss of employment or group health coverage, you will also need to complete form CMS-L564, Request for Employment Information. You can use 1 of the following options to submit your enrollment request under the Special Enrollment Period:
Fill out Section A and take the form to your employer. Ask your employer to fill out Section B. You need to get the completed form from your employer and include it with your Application for Enrollment in Medicare (CMS-40B). Then you send both together to your local Social Security office. Find your local office here: www.ssa.gov.