CMS L564

Use this form to show proof of group health plan coverage based on current employment for Medicare enrollment by completing Section A yourself and having your employer fill out Section B. Submit the completed and signed form along with your Request for Enrollment in Medicare Part B (Medical Insurance) (CMS-40B) by mail or fax to your local Social Security office, which you can locate at SSA.gov/locator. Contact Social Security at 1-800-772-1213 (TTY 1-800-325-0778) with questions.