2025 Printable Template
42,014 reviews on
This website is not affiliated with any government agency or tax authority.
Form last updated: 03/2024. Please verify this is the current version before use.
Easily complete & submit your CMS L564 form
Follow these simple steps to fill, sign, and send your CMS L564 form online.
Fill out your form
Our user-friendly editor helps you quickly enter personal & business details in the CMS L564 template.
Sign the form
Add your electronic signature to the fillable CMS L564 form to certify it came directly from you.
Send it to the requester
Download and instantly print or share your signed CMS L564 with the requester.
What is a CMS L564 used for?
Form CMS L564 is used to provide employment information necessary for individuals applying for Medicare Part B under a Special Enrollment Period. It is particularly important for those who are still employed or have a spouse who is employed, as it helps verify health insurance coverage under a group health plan.
Who needs to fill out a CMS L564 form
Individuals applying for Medicare Part B under a Special Enrollment Period who need to verify employment and group health plan coverage.
How to fill out a CMS L564 online?
Follow these steps to complete your CMS L564 form online.
Frequently Asked Questions
Find quick answers to common questions about our PDF editor.
It is used to request employment information for Medicare Part B applications under a Special Enrollment Period.
It must be completed by individuals applying for Medicare Part B who need to verify employment and group health plan coverage.
It is not required for individuals without current employment or group health plans.
The form is typically submitted to the Social Security Administration; check with the SSA for submission options.
