CMS L564

Form #
CMS L564
Form Title
REQUEST FOR EMPLOYMENT INFORMATION
Revision Date
2020-05-26
O.M.B. #
0938-0787
O.M.B. Expiration Date
2020-02-29
Special Instructions
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. 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. You’ll also need to send any required proof of employment, Group Health Plan (GHP), or Large Group Health Plan (LGHP) coverage. You can also fax your enrollment forms and evidence of employment to 1-833-914-2016. 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 to-free at 1-800-772-1213 (TTY 1-800-325-0778) for more information. NOTE: If you don’t already have Part A you can apply online at SSA.gov/benefits/medicare.