Use this form to show proof of group health plan coverage based on current employment for Medicare enrollment by completing Section A yourself and having your employer fill out Section B. Submit the …

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 the forms you need to sign up for Part B including CMS-40B, CMS-L564, CMS-10797, and CMS-10798.

Mar 21, 2025 · To prove your eligibility for an SEP, you must fill out and send Form CMS-L564 with your application. This form provides information about your or your spouse’s employment-sponsored …

Fill out the Application for Enrollment in Medicare Part B (CMS-40B) (PDF). If you are applying during the Special Enrollment Period, also fill out the Request for Employment Information (CMS-L564) (PDF).

Nov 28, 2023 · You need to submit a CMS-L564 form along with your application for Medicare if you enroll during a qualifying Special Enrollment Period. Learn what you need to complete the CMS-L564 …

Dec 17, 2025 · Step-by-step guide to the CMS L564 form. Verify employment coverage to correctly establish your Medicare payer status.

– 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 num. er. The valid OMB control number for this …

Do you need to complete the Medicare form CMS-L564? Learn who needs it and how to fill it out to avoid Part B delays or penalties.

Use this form to show proof of group health plan coverage based on current employment so you can enroll in Medicare. You complete Section A of this form, then ask your employer to fill out Section B.