Form CMS-L564 Medicare Employment Information Form (2025): Edit Online Free & Download PDF
Medicare Employment Information Form: Medicare Request for Employment Information
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Form CMS-L564 in short
Form CMS-L564 is the employer's proof that you had group health coverage through current work, so you can sign up for Medicare Part B in a Special Enrollment Period without waiting. You fill in Section A, then your employer completes and signs Section B. It goes to Social Security together with Form CMS-40B.
| Issued by | Centers for Medicare & Medicaid Services (CMS), U.S. Department of Health and Human Services |
|---|---|
| Current version | Revised 03/2025 (checked 2026-10-25) |
| Who fills it in | The person signing up for Part B completes Section A. The employer, or the group health plan for the hours bank part, completes Section B, and a company official signs it. |
| Who receives it | Your local Social Security office, along with your Form CMS-40B. |
| Where to send it | The form says to mail or fax it with your Form CMS-40B to your local Social Security office. Find an office at SSA.gov/locator. The form also lists in-person help at the local office. |
| Deadline | The form says your group health coverage must not have ended more than 8 months ago. Medicare.gov says the job-based Special Enrollment Period ends 8 months after the job or the coverage ends, whichever is first. |
| Official links | Official page · Official PDF |
What changed
The form prints 'Revised 03/2025'. CMS's form list still shows a revision date of 2023-09-30 for this form; the PDF is the newer one. CMS did not publish a list of changes.
How to fill out Form CMS-L564, line by line
| Section A | Applicant's name and SSN The name and Social Security number of the person signing up for Part B. |
| Section A | Employee's name and SSN Only if the coverage comes through someone else's job, such as a spouse. Give that worker's name and Social Security number. |
| Section A | Employer's name and address The employer that provided the group health coverage. |
| Section B, group health plans | Coverage dates The employer says whether the applicant is or was covered, when coverage started and ended (mm/yyyy), and when the employee worked there or if still employed. |
| Section B, group health plans | Large group plan months Only for a large group health plan when the applicant is disabled. List the months the plan paid first, before Medicare. |
| Section B, hours bank | Hours Bank Arrangement Only if coverage was through an hours bank. Say whether hours remain in reserve and when they ended or will be used. |
| Section B, all employers | Company official's signature Signature, date, title and phone number of a company official. |
Common mistakes to avoid
- Sending it without Form CMS-40B. The form says to send both together.
- Asking the employer to fill in Section A. You complete Section A; the employer completes Section B.
- Leaving out the employee details when coverage came through a spouse's job.
- Using it for COBRA or retiree coverage. Medicare.gov says those do not qualify for the job-based Special Enrollment Period.
- Waiting too long. The form says coverage must not have ended more than 8 months ago.
- Mailing it to the CMS Paperwork Reduction Act address. That address is only for comments on the form.
Questions about Form CMS-L564
Who fills out Form CMS-L564?
You complete Section A. Your employer completes Section B and a company official signs it.
Where do I send Form CMS-L564?
Mail or fax it together with Form CMS-40B to your local Social Security office.
When do I need Form CMS-L564?
When you sign up for Part B through a Special Enrollment Period based on group health coverage from your or your spouse's current job. Medicare.gov says you need an extra form showing that job-based coverage.
What if I am under 65 and on Medicare because of a disability?
The form says the coverage must be large group health plan coverage based on your, your spouse's or a family member's current employment.
Is there a time limit?
Yes. The form says the coverage must not have ended more than 8 months ago.
What is an Hours Bank Arrangement?
The form has a separate part for coverage through an hours bank. The employer or plan says whether reserve hours remain and when they ended or will be used.
Related forms
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Sources
Checked against the official sources on 2026-10-25. PDF Editor Hub is not affiliated with the Centers for Medicare & Medicaid Services or any government agency. This page is general information, not legal or tax advice.
- https://www.cms.gov/medicare/cms-forms/cms-forms/downloads/cms-l564e.pdf
- https://www.cms.gov/medicare/cms-forms/cms-forms/cms-forms-items/cms009718
- https://www.medicare.gov/basics/get-started-with-medicare/sign-up/when-can-i-sign-up-for-medicare
- https://www.medicare.gov/basics/get-started-with-medicare/sign-up/when-does-medicare-coverage-start