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This version of the form is not currently in use and is provided for reference only. Download this version of
Form CMS L564
for the current year.
Form CMS L564 Request for Employment Information
What Is Form CMS-L564?
Form CMS-L564, Request for Employment Information , also known as Form CMS-R-297, is a legal document you must complete to prove the group health plan coverage based on your or your spouse's current employment. This coverage must exist within the last eight months so that you can apply for Medicare in a Special Enrollment Period verifying the employment and employer health plan coverage. It is possible to be eligible for Medicare Part B only if you are currently enrolled in Medicare Part A - contact the Social Security Administration to begin the process if you are not enrolled in Part A yet.
This form was released by the Centers for Medicare & Medicaid Services , a component of the U.S. Department of Health and Human Services. The latest version of the form was issued on September 1, 2016 , with all previous editions obsolete. You can download a CMS-L564 printable version through the link below.
CMS-L564 Instructions
The first section of the Medicare Form CMS-L564 must be filled out by an individual who wishes to sign up for Medicare Part B - the employee or the employee's spouse:
- Write down the name and address of the employer;
- Indicate the date you complete the form;
- State your name and social security number;
- Record the name and social security number of the employee.
The second section of the CMS-L564 Form is to be filled out by the employer:
- State whether the applicant has been covered under an employer group health plan and record the dates this coverage began and ended;
- Indicate when the employee has worked for the company;
- List all the months when your group health plan was a primary payer if the applicant is disabled.
If you are an employer with an hour's bank arrangement, you only have to state whether the applicant has been covered under this arrangement and whether this individual has hours remaining in reserve. Specify the date the reserve hours ended or will be used.
All employers must sign and date the form, adding the title of the signing official and telephone number.
When Do I Need to Fill Out Social Security Form CMS-L564?
The process of enrolling in Medicare is more complex than it initially seems. Medicare Part B (Medical Insurance) can be applied only during certain parts of the year. Many individuals delay enrolling in Medicare because they had coverage through their job - they have a chance to complete and submit Social Security Form CMS-L564 during the Special Enrollment Period. During this time, you can qualify for health insurance if certain life events occurred: moving, losing health coverage, getting married, having a child. You may have sixty days before or sixty days after the event to enroll in a plan - it depends on your Special Enrollment Period type.
You have two other options to apply for enrollment in Medicare Part B:
- Initial Enrollment Period - it starts three months before the month you turn 65 and ends three months after the month you turn 65. Obviously, this option is not available for many individuals, so you have to wait for the Special Enrollment Period;
- General Enrollment Period - this is a period between January 1 and March 31 when you can enroll in Medicare Part B.
Where to Mail Form CMS-L564?
Once you filled out Form CMS-L564 and your employer-provided the required information, submit the document to your local Social Security office along with Form CMS-40B, Application for Enrollment in Medicare - Part B (Medical Insurance). You may visit the office in person or send the papers by mail.
Download Form CMS L564 Request for Employment Information
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