Form CMS-L564, Request for Employment Information
Form CMS-L564 is the proof behind a penalty-free late Part B enrollment: your employer certifies the group health coverage you had while you were delaying Medicare.
This is the genuine CMS PDF, unmodified. Source: CMS official page.
What is CMS-L564?
Form CMS-L564 documents that you (or your spouse) had group health plan coverage based on current employment, which is what entitles you to Medicare’s Special Enrollment Period. Section A is completed by you; Section B by the employer or group health plan, listing the coverage dates.
It always travels with Form CMS-40B, the actual Part B application. If an employer no longer exists or will not respond, SSA can accept alternative evidence such as W-2s, pay stubs showing premium deductions, or insurance cards.
Who files CMS-L564?
- Anyone claiming the Special Enrollment Period for Part B after employer coverage
- Spouses enrolling based on the working spouse’s group coverage
- The employer completes Section B; the applicant files the form
How to fill out CMS-L564
- Complete Section A with your details and the employer’s name and address.
- Ask the employer or plan administrator to complete and sign Section B with your coverage dates.
- Download the finished form and attach it to your CMS-40B.
- Submit both to your local Social Security office by mail, fax, or upload.
Quick fill CMS-L564 on this page
Prefer to see the form itself while you type? Open CMS-L564 in the editor to fill it on the actual pages, add a signature, and download.
Frequently asked questions
My former employer went out of business. Now what?
SSA accepts secondary evidence of coverage: W-2s reflecting health premiums, pay stubs, insurance cards with coverage dates, or statements from the insurer. Explain the situation when you submit.
Does COBRA count as employer coverage for this?
No. COBRA and retiree coverage are not "current employment" coverage, and time on them does not extend the Special Enrollment Period, which runs from when active employment coverage ends.