CMS (Centers for Medicare & Medicaid Services) · United States

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CMS-L564: Request for Employment Information (Medicare)

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Quick answer

Form CMS-L564, Request for Employment Information, is the Medicare Part B employer verification form that confirms the group health coverage you had through an employer or union. You complete Section A; your (or your spouse's) employer completes and signs Section B. It is submitted with Form CMS-40B to get a Special Enrollment Period and avoid a Medicare Part B late-enrollment penalty. With JustFill you upload the blank CMS PDF, fill Section A on screen, and download it free to forward to your employer.

Form
CMS-L564
Issued by
CMS (Centers for Medicare & Medicaid Services)
Country
United States
Cost to fill
Free

What is CMS-L564?

Form L564 (CMS-L564, also referenced as CMS-L564/CMS-R-297) is the Medicare Part B employer verification form — a Request for Employment Information that Medicare uses to confirm health coverage you had through an employer or union. People enrolling in Medicare Part B outside the Initial Enrollment Period — often after age 65 — submit Medicare L564 along with Form CMS-40B to avoid Late Enrollment Penalties. Section A is completed by the applicant; Section B is completed and signed by the employer's HR department.

Who fills out CMS-L564?

  • People enrolling in Medicare Part B after age 65 who had group health coverage through current employment
  • Spouses enrolling in Medicare based on the working spouse's group coverage
  • Anyone requesting a Special Enrollment Period (SEP) for Medicare Part B
  • Medicare beneficiaries appealing a Late Enrollment Penalty

Field-by-field breakdown

What each section of CMS-L564 asks for. JustFill’s AI will detect these fields automatically when you upload the PDF — review the breakdown below so you know what to enter.

Section A — Your information

Your name, Medicare number (or SSN), and signature authorizing the employer to release info.

Section B, Item 1 — Employer's name

Full legal name of the company providing the group health plan.

Section B, Item 2 — Date employment started

When you (or your spouse) started working for this employer.

Section B, Item 3 — Coverage status

Whether the applicant is currently enrolled in the group plan and on what date coverage began.

Section B, Item 4 — Coverage end date

If coverage has ended, when it ended.

Section B — Employer signature

HR representative signs, dates, and provides contact information.

Common mistakes to avoid

  • 1Submitting Section A without Section B — Medicare needs both to verify coverage and grant a Special Enrollment Period.
  • 2Listing the wrong start date for coverage — use the date the group health plan started, not the date employment began (they're often different).
  • 3Forgetting to submit alongside CMS-40B (Medicare Part B enrollment application).

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Related forms

SSA (Social Security Administration)

Form SS-5

Form SS-5: Application for a Social Security Card

Frequently asked questions

No. CMS-L564 is only needed if you're enrolling in Part B during a Special Enrollment Period (SEP), typically after age 65 when group coverage ends.
Submit both CMS-L564 and CMS-40B to your local Social Security office, or mail to the address on the Medicare enrollment instructions.
Provide documentation showing the period of group coverage (W-2s, pay stubs showing health deductions, group plan ID cards). The Social Security office accepts alternative proof when the employer refuses or no longer exists.
The current Form CMS-L564 (also labelled CMS-R-297) is published by CMS at cms.gov. Download the blank PDF there, then upload it into JustFill to complete Section A on screen and forward to your employer for Section B.
Yes. "Medicare Part B employer verification form," "Form L564," "CMS-L564," and "CMS-L564/CMS-R-297" all refer to the same Request for Employment Information used to document prior or current group health coverage when applying for Medicare Part B during a Special Enrollment Period.

Official source: CMS-L564 on CMS (Centers for Medicare & Medicaid Services)’s website

JustFill is an independent product and is not affiliated with, endorsed by, or sponsored by CMS (Centers for Medicare & Medicaid Services) or any government agency. Always verify your completed form on the official version before signing or submitting.