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 the Social Security Administration to avoid Late Enrollment Penalties. Section A is completed by the applicant; Section B is completed and signed by the employer's HR department. The blank form is a free download from CMS — you can print it, or fill it on screen and only print the finished copy.

Download the CMS-L564 form PDF — free

The official CMS-L564 form PDF is a free download from cms.gov — the file is published as CMS-L564E (the English edition; a Spanish edition exists as CMS-L564S), and the form also carries the reference number CMS-R-297. There is no fee and no registration: anyone can download and print it. Instead of printing a blank copy and filling it by hand, you can upload the same free PDF to JustFill, complete Section A on screen with every entry legible, download the result, and forward it to your employer's HR department to complete Section B. Social Security accepts the form whether it was filled by hand or on a computer — what matters is that both sections are complete and the employer has signed.

Get the official CMS-L564 PDF from CMS (Centers for Medicare & Medicaid Services)

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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We load the official CMS (Centers for Medicare & Medicaid Services) blank for you — no download needed. Or upload your own copy below.

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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 as a free PDF — no fee, no registration. Download the blank PDF there, then print it, or upload it into JustFill to complete Section A on screen and forward to your employer for Section B.
You only complete Section A: the employer's name and address, your name, your Social Security or Medicare number, and whether the coverage was through your own or your spouse's employment, then sign and date. Leave Section B blank — the employer's HR department fills in employment dates, coverage dates, and signs it. Then submit both sections together with Form CMS-40B to your local Social Security office.
Use the same form. In Section A, list your spouse's employer and check that the coverage was through a family member's employment, giving your spouse's name and SSN where asked. Your spouse's employer then completes Section B about your spouse's employment and the group coverage that included you. Each applicant needs their own CMS-L564 — if both spouses are enrolling, each submits a separate form.
The form is issued by CMS (Centers for Medicare & Medicaid Services), but you submit it to the Social Security Administration, which handles Medicare Part B enrollment. That is why instructions sometimes call it the "Social Security L564 form" — same document, submitted with CMS-40B to your local SSA office or via ssa.gov.
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.