CMS-L564 Request for Employment Information

In this article...
  • 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.

Some people decline Medicare Part B when they first become eligible for it because they are still enrolled in the health insurance plan provided by their employer or that of a spouse. 

Before you are no longer enrolled in that employer group health plan, you may want to enroll in Medicare Part B. In order to do so, you will need to qualify for a Special Enrollment Period (SEP). When you apply for Medicare, you’ll need to submit form CMS-L564 along with your Application for Medicare Enrollment.

Where Can You Get Form CMS-L564?

You can use this printable version of Form CMS-L564 provided by the official government website for Medicare.

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. 

These beneficiaries may use a Special Enrollment Period to enroll in Part B if they are still covered by the group plan or were covered by that plan within the past eight months.

How Do You Fill Out Form CMS-L564?

Form CMS-L564 has two sections that must both be filled out. You should complete section A, and the employer will fill out section B.

You’ll need the following information for section A:

  1. Name and address of your employer (or your spouse’s employer, if they are the ones who provided your previous health insurance)
  2. Your Social Security Number (SSN) or your spouse’s SSN, if they were the employee whose health insurance you were covered by

Section B must be filled out by the employer. Once they fill out section B of the form, you can submit the completed form. 

After you and the employer both complete part A and part B of Form CMS-L564, you can submit the form along with your Application for Enrollment in Medicare (Form CMS-40B).

Form CMS-40B is your actual Medicare Part B application and requires the following information:

  1. Your Medicare number
  2. Name, address and phone number
  3. Address and signature of a witness

You should submit your Form CMS-L564 and Form CMS-40B together at the same time. You may deliver the forms to your local Social Security office by mail or in person.

Important note: if you do not already have Medicare Part A, you shouldn’t complete the CMS-40B form. You should contact Social Security directly by calling 1-800-MEDICARE (1-800-633-4227) TTY: 1-877-486-2048.

Where Can You Find More Information About Special Enrollment Periods?

Medicare includes a long list of Special Enrollment Periods for various circumstances. Form CMS-L564 applies to a specific enrollment period that is granted to people who have or recently lost employer-sponsored health insurance. 

The official government website for Medicare provides more information about Medicare sign up periods and the Special Enrollment Period that applies to Form CMS-L564. 

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