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REQUEST FOR EMPLOYMENT INFORMATION. WHAT IS THE PURPOSE OF THIS FORM? In order to apply for Medicare in a Special Enrollment Period, you must have or had group health plan coverage within the last 8 months through your or your spouse’s current employment.
This information is needed to process your Medicare enrollment application. The employer that provides the group health plan coverage completes the information about your health care coverage and dates of employment.
Request for Employment Information (CMS-L564) What’s it used for? Giving the Social Security Administration proof you’re eligible to sign up for Part B if: You’re still working. You retired within the last 8 months. You lost job-based health coverage within the last 8 months.
You need to submit a CMS-L564 form along with your application for Medicare if you enroll during a qualifying Special Enrollment Period. Learn what you need to complete the CMS-L564 and what you need from your employer.
The CMS-L564 is called a request for employment information. You are responsible to fill out Section A of this form with your employer’s name and address. The purpose of this form is to verify that you’ve been employed and had employer coverage from the time you turned 65 to enrollment in Medicare.
REQUEST FOR EMPLOYMENT INFORMATION. WHAT IS THE PURPOSE OF THIS FORM? In order to apply for Medicare in a Special Enrollment Period, you must have or had group health plan coverage within the last 8 months through your or your spouse’s current employment.
Form CMS-L564 (CMS-R-297) (0 9/1 6) 2 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Form Approved OMB No. 0938-0787 REQUEST FOR EMPLOYMENT INFORMATION SECTION A: To be completed by individual signing up for Medicare Part B (Medical Insurance) 1. Employer’s Name 2. Date / / 3. Employer’s Address City State ...