# CMS L564 Form

URL: https://pdf.net/pdf-forms/healthcare-forms/cms-l-564-form
Category: Healthcare Forms
Attributes: Trusted by accountants

The CMS-L564 Form is also referred to as a **Medicare Request for Employment Information**. It proves you **have group health insurance through your current employment **when signing up for Medicare. You can access a fillable form for free and complete it with your employer in minutes using our PDF editor.

## Versions

- 2025 — [download PDF](https://cdn.sanity.io/files/i16te7yp/production/6429c31ee1801e3972f7cc0afd7bbfb80ba6af63.pdf)

## How to Fill Out a CMS-L564 Form

Step 1: Access our CMS-L564 fillable form.

Step 2: **Complete Section A** with your details.

Step 3: Send the form to your employer.

Step 4: Your employer **completes Section B** to confirm coverage.

Step 5: Check your form by reviewing the CMS-L564 Form instructions to make sure everything is correct.

Step 6: Submit it to your local Social Security office **by mail or in person.**

## Facts

### What Is the CMS-L564 Form?

The CMS-L564 Form verifies that you have or had group **health insurance through current employment**. It is required when **applying for Medicare Part B** during a Special Enrollment Period and must be completed by both you and your employer.

### Who Is Required to Fill Out the CMS-L564 Form?

**Anyone applying for Medicare Part B during a Special Enrollment Period **must fill out the CMS-L564 Form. The applicant completes Section A, and the employer providing the group health plan coverage completes Section B.

### When Is the CMS-L564 Form Due?

The CMS-L564 Form is due **when you apply for Medicare Part B during a Special Enrollment Period**. You need to submit it together with your CMS-40B application, and it must be filed **within eight months of losing employer group health coverage**.

### What Are the Penalties for Not Submitting the CMS-L564 Form?

There is **no penalty for not submitting** the CMS-L564 Form itself; however, without it, your employer coverage cannot be confirmed. Medicare may treat you as having delayed Part B and charge a late enrollment penalty that adds **10% to your premium for every 12-month period** you delayed enrollment.

### Where Do I File the CMS-L564 Form?

You file the CMS-L564 Form with Social Security; it’s possible to submit it **by mail** or deliver it **in person to your local Social Security office**, along with your CMS 40B application.

## Related forms

- [Form CMS-40B](https://pdf.net/pdf-forms/healthcare-forms/cms-40b-form)
- [Form SSA-89](https://pdf.net/pdf-forms/legal-forms/form-ssa-89)
- [1095-C Form](https://pdf.net/pdf-forms/tax-forms/1095-c-form)
- [ Form SS-5](https://pdf.net/pdf-forms/legal-forms/ss-5-form)
- [1040 Form](https://pdf.net/pdf-forms/tax-forms/1040-form)