Form CMS-R-297 Request For Employment Information

Department of Health and Human Services Centers for Medicare & Medicaid Services		Form Approved OMB No.0938-0787
_________________________________________________________________________________________ REQUEST FOR EMPLOYMENT INFORMATION
From: Social Security Administration Address:		Telephone No.
Employer’s Name and Address		Date: Employee’s Name: Employee’s Social Security Number: Claimant’s Name: Claim Number:
Dear Sir/Madam: We need the following information regarding the above claimant. Please answer the questions below, sign and date this letter and return it in the enclosed envelope or to the address given above. You may call _________________________________ at the above telephone number if you have any questions.
		Sincerely, Office Manager
Is (or was) the claimant covered under an Employer Group Health Plan? _______Yes ______ No If yes, give the original date the coverage began. ______________________ (mm/yyyy) Has the coverage ended? _______ Yes    _______ No If yes, give the date the coverage ended. ______________________                                                                   (mm/yyyy) When did the employee work for your company? From ___________________ To ­­­­­­­­­­­­____________________   Still employed ___________             (mm/yyyy)                      (mm/yyyy)
Signature and Title Of Company Official	Date Telephone Number
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0787. The time required to complete this information collection is estimated to average15 minutes per response, including the time to search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attention PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Form CMS-L564 (4/2000)