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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.
This form is used for proof of group health care coverage based on current employment. This information is needed to process your Medicare enrollment application. The employer that provides the group health plan coverage completes the information about your health care coverage and dates of employment.
Get the forms you need to sign up for Part B including CMS-40B, CMS-L564, CMS-10797, and CMS-10798.
CMS - L564. DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. REQUEST FOR EMPLOYMENT INFORMATION. Form Approved. OMB No. 0938-0787 Expires: 06/2023. WHAT IS THE PURPOSE OF THIS FORM?
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) .
You need to submit a CMS-L564 form along with your application for Medicare if you enroll during a qualifying Special Enrollment Period. Learn what you need to complete the CMS-L564 and what you need from your employer.
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...
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO.0938-0787 REQUEST FOR EMPLOYMENT INFORMATION FORM CMS-L564 (4-2000) Dear Sir/Madam: We need the following information regarding the above claimant. Please answer the questions below, sign and date this letter and return it in the enclosed ...
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.
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.