CMS Form CMS L564

2025 Printable Template

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Form last updated: 03/2024. Please verify this is the current version before use.

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How to fill out a CMS L564 online?

Follow these steps to complete your CMS L564 form online.

Step 01

Access the form in the PDF editor.

Step 02

Enter personal information in the specified fields.

Step 03

Complete the employment details section.

Step 04

Fill in the insurance coverage period.

Step 05

Have the employer sign to verify employment and coverage.

Step 06

Review the form for any inaccuracies.

Social Security Administration

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.

What is the purpose of the CMS L564 form?

It is used to request employment information for Medicare Part B applications under a Special Enrollment Period.

Who needs to fill out the CMS L564 form?

It must be completed by individuals applying for Medicare Part B who need to verify employment and group health plan coverage.

When is the CMS L564 form not necessary?

It is not required for individuals without current employment or group health plans.

How can I submit the CMS L564 form?

The form is typically submitted to the Social Security Administration; check with the SSA for submission options.

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