Request for Employment Information - CMS L564, R297

Form Approved
OMB No. 0938-0787
Expires: 06/2023

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

REQUEST FOR EMPLOYMENT INFORMATION
WHAT IS THE PURPOSE OF THIS FORM?

WHAT DO I DO WITH THE FORM?

In order to apply for Medicare in a Special Enrollment
Period, you must have or had group health plan coverage
within the last 8 months through your or your spouse’s
current employment. People with disabilities must have large
group health plan coverage based on your, your spouse’s or
a family member’s current employment.

Fill out Section A and take the form to your employer. Ask
your employer to fill out Section B. You need to get the
completed form from your employer and include it with your
Application for Enrollment in Medicare (CMS-40B). Then you
send both together to your local Social Security office. Find
your local office here: www.ssa.gov.

This form is used for proof of group health care coverage
based on current employment. This information is needed to
process your Medicare enrollment application.

GET HELP WITH THIS FORM

The employer that provides the group health plan coverage
completes the information about your health care coverage
and dates of employment.

HOW IS THE FORM COMPLETED?
•

Complete the first section of the form so that the
employer can find and complete the information about
your coverage and the employment of the person
through which you have that health coverage.

•

The employer fills in the information in the second
section and signs at the bottom.

•

Phone: Call Social Security at 1-800-772-1213

•

En español: Llame a SSA gratis al 1-800-772-1213 y oprima
el 2 si desea el servicio en español y espere a que le
atienda un agente.

•

In person: Your local Social Security office. For an office
near you check www.ssa.gov.

You have the right to get Medicare information in an accessible format, like large print, Braille, or audio. You also have the right to file a complaint if you feel
you’ve been discriminated against. Visit https://www.medicare.gov/about-us/accessibility-nondiscrimination-notice, or call 1-800-MEDICARE (1-800-633-4227)
for more information. TTY users can call 1-877-486-2048.
Form CMS L564/R297 (08/20)

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

Form Approved
OMB No. 0938-0787

REQUEST FOR EMPLOYMENT INFORMATION
SECTION A: To be completed by individual signing up for Medicare Part B (Medical Insurance)
1. Employer’s Name

2. Date

/

/

3. Employer’s Address

City

Zip Code

State

4. Applicant’s Name

5. Applicant’s Social Security Number

–
6. Employee’s Name

–

7. Employee’s Social Security Number

–

–

SECTION B: To be completed by Employers
For Employer Group Health Plans ONLY:
1. Is (or was) the applicant covered under an employer group health plan?

Yes

No

2. If yes, give the date the applicant’s coverage began. (mm/yyyy)

/
3. Has the coverage ended?

Yes

No

4. If yes, give the date the coverage ended. (mm/yyyy)

/
5. When did the employee work for your company?
To: (mm/yyyy)
From: (mm/yyyy)

/

Still Employed: (mm/yyyy)

/

/

6. If you’re a large group health plan and the applicant is disabled, please list the timeframe (all months) that your group health plan was
primary payer.
From: (mm/yyyy)

To: (mm/yyyy)

/

/

For Hours Bank Arrangements ONLY:
1. Is (or was) the applicant covered under an Hours Bank Arrangement?
2. If yes, does the applicant have hours remaining in reserve?

Yes

Yes

No

No

3. Date reserve hours ended or will be used? (mm/yyyy)

/
All Employers:
Signature of Company Official

Date Signed

/
Title of Company Official

/

Phone 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 is 0938-0787. The time required to complete this information
collection is estimated to average 15 minutes per response, including the time to review instructions, search existing data resources, gather the
data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or
suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05,
Baltimore, MD 21244-1850.
Form CMS L564/R297 (08/20)

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Form Approved
OMB No. 0938-0787

STEP BY STEP INSTRUCTIONS FOR THIS FORM
SECTION A:

The person applying for Medicare completes all of
Section A.
1. Employer’s name:
Write the name of your employer.
2. Date:
Write the date that you’re filling out the Request for
Employment Information form.
3. Employer’s address:
Write your employer’s address.
4. Applicant’s Name:
Write your name here.
5. Applicant’s Social Security Number:
Write your Social Security Number here.
6. Employee’s Name:
If you get group health plan coverage based on your
employment, write your name here. If you get group
health plan coverage through another person, like a
spouse or family member, write their name.
7. Employee’s Social Security Number:
If you get group health plan coverage based on your
employment, write your Social Security Number here. If
you get group health plan coverage through another
person, like a spouse or family member, write their Social
Security Number.

Once you complete Section A:
Once Section A is completed, give this form to your employer
to complete Section B. Once Section B has been completed
by your employer, return this form along with your Part B
application to your local Social Security office.

SECTION B:

The employer completes all of Section B.
If you’re an employer without an hours bank
arrangement, complete the section called “For
Employer Group Health Plans ONLY”
1. Is (or was) the applicant covered under an employer
group health plan?
Please check yes or no if the applicant was covered under
your group health plan offered by your company. The
applicant may be the employee or another person related
to the employee, such as a spouse or family member with
disabilities. If your company doesn’t offer a group health
plan, please check No. A group health plan is any plan
of one or more employers to provide health benefits or
medical care (directly or otherwise) to current or former
employees, the employer, or their families.
2. If yes, give the date the coverage began.
Write the month and year the date the applicant’s
coverage began in your group health plan.
3. Has the coverage ended?
Check yes or no if the group health plan coverage for the
applicant has ended.
4. If yes, give the date the coverage ended.
Write the month and year the group health plan
coverage ended for the applicant.
INSTRUCTIONS: Form CMS L564/R297 (08/20)

5. When did the employee work for your company?
Write the start and end dates of the employment for the
employee in which the applicant is related. It may be the
applicant or another person related to the employee,
such as a spouse or family member with disabilities.
Enter the month and year of the start of the employment
in the “From” box.
Enter the month and year of end of the employment in
the “To” box.
If the employee is still employed, enter the month and
year of the current date.
Current employment is active working status. It is not
disability or retirement.
6. If you’re a large group health plan and the applicant is
disabled, please list the timeframe (all months) that your
group health plan was primary payer.
Write the start and end dates that your group health plan
was primary payer for the applicant.

If you’re an employer with an hours bank
arrangement, complete the section called
“For Hours Bank Arrangements ONLY”
1. Is (or was) the applicant covered under an hours bank
arrangement?
Please check yes or no if the applicant was covered under
an hours bank arrangement. If you check no, please also
fill out the section for “Employer Group Health Plans
ONLY”.
2. If yes, does the applicant have hours remaining in
reserve?
Please indicate if the applicant currently has health
coverage based on the remaining hours in the employee’s
hours bank account.
3. Date reserve hours ended or will be used?
Please write the month and year for when the remaining
hours in the employee’s hours bank account expired or
will expire.

All employers need to complete the bottom of
Section B.
•

•
•

•

Signature of Company Official:
An official representative of the company needs to sign
this document. Please do not print.
Date Signed:
Write the date that you sign the form in this field.
Title of Company Official:
Print the title of the company official who signed the
form in this field.
Phone Number:
Write the phone number of the company official who
signed the form in this field. If there are questions
regarding the information on this form, a representative
from Social Security will contact you.

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