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2. CMS L564 | CMS - Centers for Medicare & Medicaid Services

   www.cms.gov/Medicare/CMS-Forms/CMS-Forms/CMS-Forms-Items/CMS009718

   Your employer doesn’t need to sign Section B of the CMS L564 form. State “I want Part B coverage to begin (MM/YY)” in the remarks section of the CMS 40B form or the online application. Visit faq.ssa.gov or call Social Security toll-free at 1-800-772-1213 (TTY 1-800-325-0778) for more information.

3. REQUEST FOR EMPLOYMENT INFORMATION - Centers for Medicare &...

   www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS-L564E.PDF

   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.

4. Sign up for Part B only | SSA - The United States Social Security...

   www.ssa.gov/medicare/sign-up/part-b-only

   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).

5. Enrollment Forms - Medicare

   www.medicare.gov/basics/forms-publications-mailings/forms/enrollment

   Get the forms you need to sign up for Part B including CMS-40B, CMS-L564, CMS-10797, and CMS-10798.

6. EN-05-10012- How to Apply for Medicare Part B During Your Special...

   www.ssa.gov/pubs/EN-05-10012.pdf

   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

7. How do I sign up for Medicare Part B if I already have Part A? -...

   faq.ssa.gov/en-us/Topic/article/KA-02131

   You can also fax or mail your completed Application for Enrollment in Medicare – Part B (CMS-40B) and the Request for Employment Information (CMS-L564) enrollment forms and evidence of employment to your local Social Security office. If you have questions, please contact Social Security at 1-800-772-1213 (TTY 1-800-325-0778).

8. Medicare Benefits | SSA - The United States Social Security...

   www-origin.ssa.gov/benefits/medicare

   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:

9. How to Fill out Form CMS-L564 - Disability Benefits Center

   www.disabilitybenefitscenter.org/how-to/How-to-Fill-out-Form-CMS-L564

   The Social Security Administration’s (SSA) form CMS-L564 is an employment verification form. The purpose of this form is to apply for a Special Enrollment Period (SEP) for Medicare that is outside Initial Enrollment Period (IEP) and the General Enrollment Period (GEP).

10. Social Security Form CMS-L564: Verifying Employment Information

    smartasset.com/retirement/form-cms-l564

    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...

11. CMS-L564: Request for Employment Information | CMS

    www.cms.gov/cms-l564-request-employment-information

    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. GET HELP WITH THIS FORM. Phone: Call Social Security at 1-800-772-1213.