CMS L564 | CMS
Summary: Form CMS-L564 is used by individuals to provide proof of group health plan coverage based on current employment when enrolling in Medicare Part B during a Special Enrollment Period.
Form CMS-L564 (Medicare Request for Employment Information) is an official document required for individuals who need to verify their group health plan coverage based on current employment to enroll in Medicare Part B. The form is divided into two sections: Section A, completed by the applicant, and Section B, completed by the employer. It is essential for those applying for a Special Enrollment Period, ensuring that coverage has been maintained since the first month of Medicare eligibility and has not ended more than 8 months prior. The form must be submitted alongside the Application for Enrollment in Medicare (CMS-40B) to a local Social Security office.
Document outline
1. Section A: To be completed by person signing up for Medicare Part B (Applicant information, SSN, Employer details) 2. Section B: To be completed by employer (Coverage status, start/end dates, employment duration, Hours Bank Arrangement details, and company official signature) 3. Submission Instructions: Mail or fax with CMS-40B to local Social Security office 4. Help and Resources: Contact information for Social Security, TTY, and SHIP 5. Privacy Act and Paperwork Reduction Act Statements