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

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CMS-L564: Request for Employment Information (Medicare)

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JustFill is not affiliated with CMS (Centers for Medicare & Medicaid Services). This is an independent third-party tool to help you complete CMS-L564. Always download the current blank form from the official source and verify your completed copy before signing or submitting. Official CMS-L564 from CMS (Centers for Medicare & Medicaid Services)

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 Social Security — online, by fax, or by mail to your local office — to use a Special Enrollment Period and avoid a Part B late-enrollment penalty. The current print is Revised 03/2025, a free two-page fillable PDF from CMS. JustFill opens that blank in one click so you can fill Section A on screen; the first clean completed download is included at no charge, and you then forward it to the employer for Section B.

Form
CMS-L564
Issued by
CMS (Centers for Medicare & Medicaid Services)
Country
United States
Free allowance
First clean download
Official edition
Form CMS-L564 (Revised 03/2025), OMB No. 0938-0787, expires 03/2028 — two-page fillable PDF (CMS-L564E). The CMS forms-list entry still shows a 2023-09-30 revision date, but the PDF it links to is the 03/2025 print
Source checked

What is CMS-L564?

Form L564 (CMS-L564; older prints also carried the number CMS-R-297, which the current 03/2025 print no longer shows) 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 (your name and SSN, the employee’s name and SSN if the coverage came through a spouse, and the employer’s name and address) is completed by the applicant; Section B (coverage and employment dates) is completed and signed by a company official. To qualify for the Special Enrollment Period you must have had group health plan coverage through your or your spouse’s current employment since you first became eligible for Part B, and the coverage must not have ended more than 8 months ago. The blank form is a free download from CMS — print it, or fill it on screen and print only the finished copy.

Download the CMS-L564 form PDF — free

The official CMS-L564 PDF is a free download from CMS at cms.gov/medicare/cms-forms/cms-forms/downloads/cms-l564e.pdf — the current print is “Form CMS-L564 (Revised 03/2025)”, OMB 0938-0787, expiring 03/2028, two pages, and the file is already a fillable PDF (the E in CMS-L564E means English; a Spanish edition, CMS-L564S, sits alongside it). Social Security links to the same PDF from its “Sign up for Part B only” page. There is no fee and no registration. JustFill carries this exact blank, so you can open it in one click, complete Section A on screen with every entry legible, and download it — the first clean completed download is included at no charge — then forward it to the employer’s HR department for 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 a company official 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
  • People under 65 who qualify for Medicare through disability and had large group health plan coverage through their own, a spouse’s, or a family member’s current employment

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 and Social Security number; the employee’s name and SSN if the coverage came through your spouse; and the employer’s name and full address. There is no signature line in Section A on the 03/2025 print.

Section B — Group health plan coverage

The employer confirms whether you are (or were) covered under its group health plan and gives the month and year the coverage started (mm/yyyy).

Section B — Coverage end date

Whether the coverage has ended and, if so, the month and year it ended — this date drives the 8-month Special Enrollment Period.

Section B — Employment dates

When the employee worked for the company: from and to (mm/yyyy), or “still employed”.

Section B — Disability and Hours Bank questions

For large group health plans, the months the plan was primary payer for a disabled applicant; and whether the applicant was covered under an Hours Bank Arrangement, has reserve hours left, and when they end.

Section B — Employer signature

A company official signs and dates (mm/dd/yyyy) and adds their title and phone number — Social Security expects this signature unless the employer cannot complete the form.

Common mistakes to avoid

  • 1Submitting Section A without Section B — Medicare needs both to verify coverage and grant a Special Enrollment Period.
  • 2Mixing up the two date sets in Section B — the employer must give both when the group coverage started and ended (mm/yyyy) and, separately, when the employee worked for the company; they are often different and Social Security uses the coverage dates for the Special Enrollment Period.
  • 3Sending it without Form CMS-40B (07/2025), the Part B enrollment application — Social Security needs both, and its guidance asks you to write “I want Part B coverage to begin (MM/YY)” in the CMS-40B remarks.

CMS-L564 example — what a filled-out form looks like

A fictional applicant, Maria Sample, turned 65 in 2023 but stayed on her husband Luis’s employer plan instead of taking Part B. Luis retires at the end of October 2026 and the plan ends the same month, so Maria signs up for Part B in a Special Enrollment Period and needs his employer to confirm the coverage.

Section A — Applicant’s name

Maria Sample

The person enrolling in Part B, even when the coverage came through a spouse.

Section A — Applicant’s Social Security Number

•••-••-•••• (the full number from her Social Security card)

The form asks for the SSN, not the Medicare number.

Section A — Employee’s name (if different from applicant)

Luis Sample

The spouse whose job provided the group health plan. Leave it blank when the coverage was through your own job.

Section A — Employee’s SSN (if different)

•••-••-•••• (Luis’s number)

Lets Social Security match the employer’s answers to the right worker.

Section A — Employer’s name and address

Sample Logistics Inc., 100 Example Way, Springfield, IL 62701

The employer that sponsored the plan; this is who Social Security may contact.

Section B — Is (or was) the applicant covered under an employer group health plan?

Yes · coverage started 06/2019

Completed by the employer. Dates are month and year only (mm/yyyy).

Section B — Did the coverage end?

Yes · 10/2026

To use the Special Enrollment Period the coverage must not have ended more than 8 months earlier.

Section B — When did the employee work for your company?

From 06/2019 · To 10/2026 · Still employed: No

Employment dates are asked separately from coverage dates; they are often different.

Section B — Large group health plan / disability months and Hours Bank questions

Left blank · Hours Bank: No

The disability line is only for applicants who qualify for Medicare through disability; the Hours Bank block applies to plans that bank hours, typically union plans.

Section B — Signature of company official

HR manager signs, dates (mm/dd/yyyy), adds title and phone number

Social Security expects the employer’s signature. If the employer will not or cannot sign, see the FAQ on secondary evidence.

These values are made up. They are here to show what belongs on each line, not to be copied — every name, number, and address on your own CMS-L564 has to be your own.

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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.
Three routes, all through Social Security: (1) online — start the Part B application at ssa.gov/medicare/sign-up/part-b-only and upload the completed CMS-L564 (or an employer letter) with your CMS-40B; (2) fax both forms to your local Social Security office; or (3) mail them to that office. Find the office, its fax number and address at ssa.gov/locator. Nothing is sent to CMS or to Medicare directly.
Social Security’s instructions say to complete Section B yourself as best you can on the employer’s behalf, leave the signature blank, and submit secondary evidence of the coverage: income tax returns showing health insurance premiums paid, W-2s reflecting pre-tax medical contributions, pay stubs showing premium deductions, health insurance cards with a policy effective date, explanations of benefits from the plan, or statements or receipts showing premium payments.
The current Form CMS-L564 (Revised 03/2025, OMB 0938-0787) is published by CMS at cms.gov/medicare/cms-forms/cms-forms/downloads/cms-l564e.pdf as a free fillable PDF — no fee, no registration. Download it there and print it, or open the same blank in JustFill with one click to complete Section A on screen; the first clean completed download is included at no charge, and you then forward it to the employer for Section B.
You only complete Section A: your name and Social Security number, the employee’s name and SSN if the coverage was through your spouse, and the employer’s name and address. There is no signature or checkbox in Section A on the current print. Leave Section B blank — a company official fills in whether you were covered, the coverage start and end months, the employment dates, and signs. Then send both sections with Form CMS-40B to Social Security — online, or by fax or mail to your local office.
Use the same form. In Section A, enter yourself as the applicant, your spouse as the employee (with their SSN), and your spouse’s employer. That 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 with a separate CMS-40B.
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 the older "CMS-R-297" number 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.
Yes. The official CMS-L564E.pdf from cms.gov is a fillable PDF with typed fields for both Section A and Section B. You can type into it in any PDF reader, or open it in JustFill in one click to fill Section A in your browser and download the result — the first clean completed download is included at no charge. Either way, the company official’s signature in Section B still has to be written in.
Yes. Social Security’s online Part B application (“Start application” on ssa.gov/medicare/sign-up/part-b-only) lets you complete CMS-40B online and upload the employer-signed CMS-L564, or a letter, fax, or email from the employer or plan confirming the coverage, when you apply during a Special Enrollment Period. JustFill does not submit anything to Social Security; it only produces the completed PDF you upload.

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

Edition checked: Form CMS-L564 (Revised 03/2025), OMB No. 0938-0787, expires 03/2028 — two-page fillable PDF (CMS-L564E). The CMS forms-list entry still shows a 2023-09-30 revision date, but the PDF it links to is the 03/2025 print. Verified against the official source on .

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