REQUEST FOR EMPLOYMENT INFORMATION
O.M.B. Expiration Date
Return the completed form to your local Social Security office by mail, or fax to 1-833-914-2016. You can call Social Security toll-free at 1-800-772-1213 or at their TTY number, 1-800-325-0778, if you’re deaf or hard of hearing. Get answers to frequently asked questions at www.ssa.gov. NOTE: If you are eligible to enroll under the Special Enrollment Period and unable to mail your CMS 40-B, Application for Enrollment in Medicare - Part B (Medical Insurance) along with the CMS L564- Request for Employment Information, and proof of employment, Group Health Plan (GHP), or Large Group Health Plan (LGHP) fax them to 1-833-914-2016. Your employer does not need to sign Part B of the CMS L564 form. State on the CMS L564 form “I want Part B (and Part A, if applicable) coverage to begin (MM/YY)”.