How to Complete Form CMS-L564
Form CMS-L564 is the "Request for Employment Information" form. It is required when you are enrolling in Medicare Part B under a Special Enrollment Period (SEP) based on employer group health plan coverage.
What Is Form CMS-L564?
Form CMS-L564 is used to verify that you (or your spouse) had employer group health plan (GHP) coverage based on current employment. This verification is required by Social Security when you apply for Medicare Part B outside of your Initial Enrollment Period using a Special Enrollment Period.
Without this form — properly completed and signed by your employer — Social Security cannot confirm your SEP eligibility, and your Part B enrollment may be delayed or denied.
When Do You Need This Form?
You need Form CMS-L564 when you are applying for Medicare Part B under a Special Enrollment Period because:
- You delayed enrolling in Part B because you were covered by an employer group health plan through your own or your spouse's current employment.
- You are now losing that employer group health plan coverage (e.g., due to retirement, job loss, or the employer ending coverage).
- You want to enroll in Part B within 8 months of losing that employer coverage.
How to Complete Each Section
Section A – Beneficiary Information
Name
Enter your full legal name as it appears on your Medicare card.
Medicare Claim Number (HICN) or Medicare Beneficiary Identifier (MBI)
Found on your red, white, and blue Medicare card.
Date of Birth
Your date of birth in MM/DD/YYYY format.
Sex
Check the appropriate box.
Section B – Employer Information
Employer Name
The name of the employer who provided the group health plan coverage.
Employer Address
Full mailing address of the employer.
Employer Phone Number
A contact number for the employer or HR department.
Section C – Employer Certification
Period of Coverage
The start and end dates of the employer group health plan coverage. This is critical — it must cover the period you are claiming.
Type of Coverage
Whether coverage was based on current employment or disability.
Authorized Signature
Must be signed by an authorized representative of the employer (HR, benefits administrator, etc.).
Title and Date
The signer's job title and the date they signed the form.
Important Tips
Section C must be completed by your employer — not by you. If your employer refuses or is unavailable, contact Social Security at 1-800-772-1213 for guidance on alternative documentation.
- The form must be completed and signed by your employer — you cannot sign Section C yourself.
- Make sure the dates of coverage in Section C align with the period you are claiming for your Special Enrollment Period.
- If your employer no longer exists, contact the plan administrator or insurance carrier directly for alternative documentation.
- Keep a copy of the completed form for your records before submitting.
- Submit CMS-L564 together with Form CMS-40B when applying for Medicare Part B under a Special Enrollment Period.
Where to Submit the Form
Submit Form CMS-L564 along with Form CMS-40B to your local Social Security office. You can:
- Mail both forms to your local Social Security Administration office.
- Bring them in person to a Social Security office.
- In some cases, fax them — call Social Security first to confirm the fax number.
Social Security Administration: 1-800-772-1213 (TTY: 1-800-325-0778)