Crosswalk

Revisions to Form CMS 18F5 (OMB 0938-0251) Application for Medicare Part A (Hospital Insurance)

The form has been updated to remove the checkbox that authorized the sending of emails to beneficiaries regarding their benefits and coverage. The burden has not been impacted by the changes.

Changes

Updated Form	Original Form	Reason for Change
Page 1 Heading: “What information do you need to complete this application? “ Form CMS-L564 Medicare Request for Employment Information	Page 1 Heading: “What information do you need to complete this application?” Form CMS-L564 Request for Employment Information	The word ‘Medicare’ has been added to the CMS L564’s title per CMS’ Office of Communications suggestion, to specify the form is used for a ‘Medicare’ request for Employment information. The new form and title were approved by OMB 3/7/25.
1g. PO Box	1g. P.O. Box	The abbreviation for Post Office Box is PO Box, not P.O. Box Source: https://www.usps.com/manage/po-boxes.htm
1j. Email Address. The checkbox is removed.	1j. The email address field is followed by a check box for authorization for Social Security and Medicare to send emails to beneficiaries emails about their benefits and coverage, along with consent to the Privacy Act Statement on the previous page.	The form has been updated to remove the checkbox that authorized the sending of emails to beneficiaries regarding their benefits and coverage. As part of the review process for other Medicare enrollment form renewal requests, the OMB directed the CMS to standardize the collection of email addresses across all enrollment forms. The collection of email addresses will now be treated in the same way as the collection of a beneficiary's address and phone number, meaning that additional authorization is not required for this information.