Centers for Medicare & Medicaid Services

Fill out Form CMS-L564 online

Medicare Request for Employment Information

Form CMS-L564 gives Social Security proof of group health plan coverage based on current employment, so you can sign up for Medicare Part B during a Special Enrollment Period. You fill in Section A, and the employer fills in Section B, which a company official signs. On paper, you send it together with your Application for Enrollment in Medicare (CMS-40B).

Fill out Form CMS-L564 Blank form from the CMS

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Edition: (03/2025)
Pages: 2
Fillable fields: 45
Checked against the CMS: November 8, 2026

GuruPDF is not affiliated with the Centers for Medicare & Medicaid Services. This page explains the form in plain words; it is not legal or tax advice. Always check the official instructions before you file.

Who uses Form CMS-L564

People signing up for Part B who are still working and have group health plan coverage through that job
People signing up for Part B who retired or lost job-based health coverage within the last 8 months
People whose group health plan coverage comes through a spouse's current job
People with Medicare because of a disability whose large group health plan coverage is based on their own, a spouse's or a family member's current job
Employers, including those with an hours bank arrangement, that complete and sign Section B

Before you start

Your name and Social Security Number
The name and Social Security Number of the person whose job provides the coverage, if that is not you
The employer's name and full address
Someone at the employer who can complete Section B, and a company official who can sign it
Your Application for Enrollment in Medicare (CMS-40B), which is sent with this form

How to fill out Form CMS-L564

Section A: applicant and employee
Enter the applicant's name and Social Security Number. If the coverage comes through someone else's job, such as a spouse or family member, enter that person's name and SSN under "Employee's name (if different from applicant)" and "Employee's SSN (if different)". These two fields are only for a person other than the applicant.
Section A: employer
Enter the employer's name, address, city, state and ZIP code. This is the employer whose group health plan provides the coverage. Then give the form to that employer so it can complete Section B.
Section B: For Employer Group Health Plans ONLY
The employer checks Yes or No for whether the applicant is or was covered under an employer group health plan and, if yes, gives the month and year the coverage started. It then checks whether the coverage ended and, if it did, gives the month and year it ended.
Section B: employment dates and disability
Still in the group health plan part, the employer enters when the employee worked for the company (From and To, mm/yyyy) and checks Yes or No for "Still employed?". If the employer is a large group health plan and the applicant is disabled, it also lists all months its group health plan was the primary payer.
Section B: For Hours Bank Arrangements ONLY
This part is only for coverage under an hours bank arrangement. The employer checks whether the applicant is or was covered under one and, if yes, whether the applicant has hours left in reserve. It then gives the month and year the reserve hours ended or will be used.
Section B: All Employers
Every employer completes this part. A company official signs, enters the date signed (mm/dd/yyyy), their title and a phone number. CMS's instructions say Social Security may contact the official if it has questions about the information on the form.

After you fill it out

Once the employer has completed and signed Section B, get the form back. Mail or fax it, together with your Application for Enrollment in Medicare (CMS-40B), to your local Social Security office; the form points to SSA.gov/locator to find one. Social Security also lets you apply online for Part B during this Special Enrollment Period; see its Part B sign-up page on SSA.gov.

Signing: Only a company official at the employer signs, in the "All Employers" part of Section B; the form has no signature line for the applicant. The official instructions do not say whether an electronic signature is accepted, so follow Social Security's instructions.

Watch out for

This form alone does not sign you up for Part B. On paper, it goes with the Application for Enrollment in Medicare (CMS-40B).
If your employer cannot fill out Section B, do not sign it yourself. Medicare.gov says to complete Section B as best you can, leave it unsigned and send proof of your job-based health insurance.
Medicare.gov says COBRA is not group health plan coverage for this Special Enrollment Period, and the end of COBRA or retiree coverage does not qualify you for one.
This Special Enrollment Period ends 8 months after the group health plan coverage or the employment ends, whichever happens first.

Questions about Form CMS-L564

Who fills out each section of Form CMS-L564?

The person signing up for Part B completes Section A. The employer completes Section B, and a company official signs it.

What if my employer cannot complete Section B?

Medicare.gov says to fill out Section B as best you can but not to sign it. You will also need to send proof of your job-based health insurance.

Does COBRA or retiree coverage count?

No. Medicare.gov says COBRA is not considered group health plan coverage, and getting COBRA does not change when this Special Enrollment Period ends. The end of COBRA or retiree coverage is not a situation that qualifies for a Special Enrollment Period.

What does "current employment" mean?

CMS's instructions describe current employment as active working status, not disability or retirement. The coverage must be based on your own or your spouse's current job or, if you have Medicare because of a disability, a family member's current job.

Can everyone use this Special Enrollment Period?

No. Medicare.gov says it does not apply if you are eligible for Medicare based on End-Stage Renal Disease (ESRD), or if you are still in your Initial Enrollment Period.