Fillable Form CMS L564

What is Form CMS L564?

Form CMS L564, Request for Employment Information, is a Social Security Administration (SSA) form used to apply for Medicare in a Special Enrollment Period (SEP).

In order to apply for Medicare in a Special Enrollment Period, you must have or had group health plan coverage within the last eight (8) months through your or your spouse’s current employment. People with disabilities must have large group health plan coverage based on their, their spouse’s, or their family member’s current employment.

Form L564 CMS 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 your group health plan coverage completes the information required on CMS Form L564 about your health care coverage and dates of employment.

You must complete the first section of the form so that your employer can find and complete the information about your coverage and your employment through which you have that health coverage. Your employer then fills in the information in the second section and signs at the bottom section of the form.

After you and your employer fill out the form, you need to get the completed Form CMS L564 from your employer and include it with your Form CMS 40B, Application for Enrollment in Medicare. Then, you send both forms together to your local Social Security office. You can find the nearest local Social Security office near you via the official website of the Social Security Administration (SSA). For inquiries, you may contact Social Security at 1-800-772-1213.

How to fill out Form CMS L564?

Using PDFQuick, you can electronically fill out and download a PDF copy of the CMS L564 form in minutes. Fill it out by following the instructions below.

Section A

For completion of the individual applying for Medicare (medical insurance).

Line 1

Enter the full name of your employer.

Line 2

Enter the date you’re filling out the Request for Employment Information form, following the format: MM/DD/YYYY.

Line 3

Enter your employer’s complete address, including street number, city, state, and ZIP code.

Line 4

Enter your full name.

Line 5

Enter your social security number (SSN).

Line 6

If you get group health plan coverage based on your employment, enter your full name. If you get group health plan coverage through another person (for example: a spouse or a family member), enter their full name.

Line 7

If you get group health plan coverage based on your employment, enter your social security number (SSN). If you get group health plan coverage through another person (for example: a spouse or a family member), enter their social security number (SSN).

Section B

For completion of the employer.

For Employer Group Health Plans

For completion of an employer without an hours bank arrangement.

Line 1

Mark the appropriate box if the applicant was covered under your group health plan offered by your company. You may select:

The applicant may be the employee or another person related to the employee, such as a spouse or family member with disabilities.

If your company doesn’t offer a group health plan, mark the “No” box. A group health plan is any plan of one or more employers to provide health benefits or medical care (directly or otherwise) to current or former employees, the employer, or their families.

Line 2

If you marked the “Yes” box on the preceding line, enter the date the applicant’s coverage began in your group health plan, following the format: Month, Year.

Line 3

Mark the appropriate box if the group health plan coverage for the applicant has ended. You may select:

Line 4

If you marked the “Yes” box on the preceding line, enter the date the group health plan coverage ended for the applicant, following the format: Month, Year.

Line 5

Enter the start and end dates of the employment of the employee to which the applicant is related. It may be the applicant or another person related to the employee, such as a spouse or family member with disabilities. 

Enter the month and year of the start of the employment in the “From” box.

Enter the month and year of the end of the employment in the “To” box.

If the employee is still employed, enter the month and year of the current date in the “Still Employed” box.

Current employment is active working status. It is not disability or retirement.

Line 6

If you’re a large group health plan and the applicant is disabled, enter the timeframe (all months) that your group health plan was the primary payer for the applicant.

Enter the month and year your group health plan started as the primary payer in the “From” box.

Enter the month and year your group health plan ended as the primary payer in the “To” box.

For Hours Bank Arrangements

For completion of an employer with an hours bank arrangement.

Line 1

Mark the appropriate box if the applicant was covered under an hours bank arrangement. You may select:

If you marked the “No” box, make sure to fill out the “For Employer Group Health Plans” section.

Line 2

If you marked the “Yes” box on the preceding line, mark the appropriate box if the applicant currently has health coverage based on the remaining hours in the employee’s hours bank account. You may select:

Line 3

Enter the date when the remaining hours in the employee’s hours bank account expired or will expire, following the format: Month, Year.

Signature of Company Official

Affix the signature of an official representative of the company.

Date Signed

Enter the date of when the company official signed the form.

Title of Company Official

Enter the title of the company official who signed the form. 

Phone Number

Enter the phone number of the company official who signed the form.

If there are questions regarding the information on this form, a representative from Social Security will contact you.