Fill Out Form CMS-L564 Online
Request for Employment Information
Centers for Medicare & Medicaid Services
Documents group health coverage through an employer to support special enrollment in Medicare Part B, completed with Form CMS-40B.
Reviewed July 2026
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Form CMS-L564, Request for Employment Information, is the proof-of-coverage form used when you enroll in Medicare Part B during a special enrollment period. It documents that you were covered by a group health plan through your own or your spouse's current employment, which is what lets you enroll late without a penalty.
You can start the L564 in the Universal PDF editor by completing the applicant section, then download the PDF for the employer to finish and sign. It is submitted together with Form CMS-40B, the Part B enrollment application.
What is Form CMS-L564 used for
When you delay Part B because you had employer coverage, Social Security needs evidence of that coverage before it grants a special enrollment period. The L564 is that evidence: it records who the employer is, whose employment the coverage was based on, and the dates the group health plan coverage started and ended.
Without this documentation or an acceptable substitute, a late Part B enrollment could be treated as ordinary late enrollment, which can carry a lasting premium penalty.
Who files Form CMS-L564
The form is completed by two parties. The applicant, the person enrolling in Part B, fills out Section A with identifying information about the employer and the employee whose coverage applies. The employer, typically the human resources or benefits office, completes Section B with the employment dates and group health plan coverage dates, then signs it.
If the coverage came through your spouse's job, your spouse is the employee listed on the form, and their employer completes Section B.
How to fill out Form CMS-L564
Split the work between the two sections:
- Section A, completed by the applicant: the employer's name and address, the date of your request, your name and Social Security number, and the employee's name and Social Security number if the coverage was through a spouse
- Section B, completed by the employer: whether the applicant or spouse was employed, employment start and end dates, whether they had group health plan coverage, and the coverage start and end dates, followed by the signature of a company official
- Ask the employer to answer every applicable line; incomplete coverage dates are a common reason applications need follow-up
Where to send it
Submit the completed L564 to the Social Security Administration together with Form CMS-40B. You can mail or fax the pair to your local Social Security office, and SSA offers an online submission path for special enrollment through ssa.gov. If a former employer no longer exists or cannot complete Section B, contact Social Security about acceptable alternative evidence of your group coverage, such as pay stubs showing premium deductions or plan documents.
Frequently asked questions
No. It is required when you enroll during a special enrollment period based on employer group health coverage. If you enroll during your initial enrollment period or the general enrollment period, the L564 is not part of the process.
You complete Section A with identifying information, and the employer that provided the group health coverage completes and signs Section B with employment and coverage dates.
Contact Social Security. Alternative evidence of group health coverage, such as pay stubs showing health insurance deductions, W-2 notations, or plan documents, may be accepted in place of a completed Section B.
Yes. Section A has space to identify the employee whose employment the coverage was based on, so list your spouse as the employee and have their employer complete Section B.
With Form CMS-40B, the Application for Enrollment in Medicare Part B. The two forms go to the Social Security Administration together by mail, fax, or SSA's online special enrollment process.
Yes. Complete Section A in the Universal PDF editor, download the PDF, and send it to the employer to complete and sign Section B before you submit it with your CMS-40B.
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