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You can complete the Part B SEP online or you can mail your completed CMS 40B, Application for Enrollment in Medicare - Part B (Medical Insurance) and CMS L564 - Request for Employment Information to your local Social Security office.
Fill out the Application for Enrollment in Medicare Part B (CMS-40B) (PDF). If you are applying during the Special Enrollment Period, also fill out the Request for Employment Information (CMS-L564) (PDF).
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.
As most of you know, this “Request for Employment Information” form is required if your employee is over the age of 65 and outside of their initial enrollment period for Medicare. They must submit this form with their Medicare Part B enrollment form to qualify for a Special Enrollment Period to sign up for their Medicare upon retirement.
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 Zip Code 4. Applicant’s Name 5. Applicant’s Social Security Number – – 6. Employee’s Name 7. Employee’s Social Security Number ...
If you qualify for an SEP, you can apply online at Apply for Medicare Part B Online during a Special Enrollment Period. You can also fax or mail your completed Application for Enrollment in Medicare – Part B (CMS-40B) and the Request for Employment Information (CMS-L564) enrollment forms and evidence of employment to your local Social ...
Form CMS-L564 is a form used by the Social Security Administration to grant a Special Enrollment Period to Medicare beneficiaries who initially turned down Part B coverage because they were receiving group health benefits from their employer or a spouse’s employer.