Form CMS-L564, Medicare Request for Employment Information, is issued by the Centers for Medicare & Medicaid Services (CMS) to show proof of group health plan coverage based on current employment when you enroll in Medicare. You complete Section A, then your employer completes Section B. On this page you can fill out the form online on FillingPDF and download or print the completed PDF. The form is sent to your local Social Security office together with your Application for Enrollment in Medicare (CMS-40B).
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What is CMS-L564?
Form CMS-L564, Medicare Request for Employment Information, is the Centers for Medicare & Medicaid Services (CMS) form that shows proof of group health plan coverage based on current employment, so that a person can enroll in Medicare Part B (Medical Insurance).
The form has two parts. In Section A, the person signing up for Medicare Part B gives the applicant's name and Social Security Number (SSN), the employee's name and SSN if the employee is a different person, and the employer's name and address. In Section B, the employer answers questions about the coverage. Employer group health plans report whether the applicant is or was covered, when coverage started and ended, and the dates the employee worked for the company. A large group health plan covering a disabled applicant also lists the months it was the primary payer. Employers with an Hours Bank Arrangement answer a separate set of questions about reserve hours. A company official signs and dates the form.
CMS-L564 is not the enrollment application. It travels with the Application for Enrollment in Medicare (CMS-40B) and is sent with it to your local Social Security office. The form is approved under OMB No. 0938-0787, expires 03/2028 and is marked Revised 03/2025. CMS estimates it takes an average of 15 minutes per response.
Who needs to file CMS-L564?
The main group is people enrolling in Medicare Part B through a Special Enrollment Period who had group health plan coverage through their own or their spouse's current employment. The form says that coverage must have existed since the first month you were eligible for Medicare Part B, and that it must not have ended more than 8 months ago.
Other groups and roles:
- People who qualify for Medicare because of a disability. The form says you must have large group health plan coverage based on your, your spouse's or a family member's current employment.
- Employers. A company official completes and signs Section B. The applicant does not fill in that section.
- Spouses and family members. When the coverage comes through someone else's job, the applicant's details go in the applicant lines and the employee's name and SSN go in the lines marked "if different."
The form does not describe any representative or alternate signer for Section A. Questions about whether you qualify can go to Social Security at 1-800-772-1213 (TTY 1-800-325-0778) or to a State Health Insurance Program (SHIP) at shiphelp.org.
When to file CMS-L564
Submit Form CMS-L564 when you apply for Medicare Part B and need to show group health plan coverage based on current employment. It goes in with your Application for Enrollment in Medicare (CMS-40B), so there is no separate due date printed on the form. For a Special Enrollment Period, the form says your coverage must not have ended more than 8 months ago. Because your employer must complete Section B before you send the package, ask for it early. Missing information can delay your enrollment application, according to the form's Privacy Act Statement.
Documents you need
- Application for Enrollment in Medicare (CMS-40B): mail or fax it with this form to your local Social Security office.
- Section B completed and signed by a company official: the employer fills in the coverage and employment questions, signs, dates (mm/dd/yyyy) and adds a title and phone number.
How to fill out CMS-L564
Enter the applicant's details
In Section A, type the applicant's name and the applicant's Social Security Number (SSN). The applicant is the person signing up for Medicare Part B.
Add the employee's details if different
If the coverage comes through a spouse or family member's job, enter the employee's name and the employee's SSN. Leave these lines blank when the applicant is the employee.
Enter the employer's information
Type the employer's name, the employer's address, and the City, State and ZIP code.
Pass the form to your employer
Section A is yours; the employer completes Section B. Share the form with the employer's company official before you finish.
Answer the group health plan questions
For Employer Group Health Plans ONLY, mark Yes or No for whether the applicant is or was covered. If yes, enter the start date as mm/yyyy; mark whether coverage ended and, if yes, enter the end date as mm/yyyy.
Enter the employment dates
Under "When did the employee work for your company?", enter From and To dates as mm/yyyy and mark whether the employee is still employed.
List primary payer months if disabled
A large group health plan with a disabled applicant lists From and To (mm/yyyy) for all months the plan was the primary payer. Skip this line otherwise.
Complete the Hours Bank section if needed
For Hours Bank Arrangements ONLY, mark whether the applicant is or was covered and whether hours remain in reserve. Enter the date reserve hours ended or will be used as mm/yyyy.
Add the company official's signature block
Under All Employers, the company official signs, enters the date signed as mm/dd/yyyy, and adds their title and phone number.
Review and download the completed PDF
Check that names and SSNs are correct and both sections are complete. Download or print the completed PDF from FillingPDF and send it with the CMS-40B as described under How to submit.
How to submit CMS-L564
You can mail or fax Form CMS-L564 to your local Social Security office. Send it together with your Application for Enrollment in Medicare (CMS-40B).
- Mail or fax: send the completed, employer-signed form and the CMS-40B to your local Social Security office. The form prints no street address or fax number; find your office at SSA.gov/locator.
- Phone: call Social Security at 1-800-772-1213 (TTY 1-800-325-0778). Spanish service is available at the same number; press 2.
- In person: visit your local Social Security office for help with the form.
- Counseling: a State Health Insurance Program (SHIP) offers free insurance counseling at shiphelp.org.
Do not send this form, or any item with your personal information such as claims, payments or medical records, to the CMS PRA Reports Clearance Office in Baltimore. That address is only for comments on the form's time estimate, and items sent there are destroyed and not forwarded to Social Security. FillingPDF lets you fill out and download the PDF; submission follows the channels above.
Common mistakes to avoid
- Sending Form CMS-L564 alone; the form says to mail or fax it together with the Application for Enrollment in Medicare (CMS-40B).
- Filling in Section B yourself; the form says your employer completes Section B, and a company official must sign it.
- Mailing the form to the CMS PRA Reports Clearance Officer in Baltimore; that address is only for comments on the time estimate, and items sent there are destroyed.
- Relying on coverage that ended more than 8 months ago for a Special Enrollment Period; the form says coverage must not have ended more than that.
- Leaving the employee's name and SSN out when the coverage comes through a spouse or family member; those lines are for an employee who differs from the applicant.
- Writing coverage and employment dates in the wrong format; Section B asks for mm/yyyy, while the date signed uses mm/dd/yyyy.
- Answering the Hours Bank Arrangement questions when the employer has no such arrangement; that part is for Hours Bank Arrangements only.
- Leaving information blank; the form's Privacy Act Statement says missing information can delay your enrollment application.
Frequently asked questions
What is Form CMS-L564 used for?
Form CMS-L564 shows proof of group health plan coverage based on current employment so you can enroll in Medicare Part B. You complete Section A, and your employer completes Section B with the coverage and employment details.
Who fills out each section of the CMS-L564 form?
The person signing up for Medicare Part B completes Section A: names, SSNs and the employer's name and address. The employer completes Section B, including dates of coverage and employment, and a company official signs and dates it.
Where do I send Form CMS-L564?
Mail or fax it, together with your Application for Enrollment in Medicare (CMS-40B), to your local Social Security office. The form prints no address or fax number; find your office at SSA.gov/locator or call 1-800-772-1213.
Can I fill out Form CMS-L564 online?
Yes. You can fill out the PDF online on FillingPDF and download or print it. FillingPDF does not send it to Social Security or CMS; you mail or fax it with the CMS-40B yourself, after your employer completes Section B.
How recently must my employer coverage have ended for a Special Enrollment Period?
No more than 8 months ago. The form says you must have had group health plan coverage through your or your spouse's current employment since the first month you were eligible for Medicare Part B, and that coverage must not have ended more than 8 months ago.
Do I need CMS-L564 if I qualify for Medicare because of a disability?
The form applies to you if you have large group health plan coverage based on your, your spouse's or a family member's current employment. In that case the employer also lists the months the plan was primary payer in Section B.
What is the Hours Bank Arrangement section for?
It is for employers with an Hours Bank Arrangement only. The employer marks whether the applicant is or was covered, whether hours are left in reserve, and the date reserve hours ended or will be used (mm/yyyy).
Where can I get help with the CMS-L564 form?
Call Social Security at 1-800-772-1213 (TTY 1-800-325-0778), or visit a local Social Security office. Spanish speakers can press 2 at the same number. A State Health Insurance Program (SHIP) at shiphelp.org gives free counseling.
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