This form PROVES you had employer coverage — without it, you may face late enrollment penalties

Have your employer's HR department fill out Section B

If your employer no longer exists, contact the plan administrator or insurance company for a coverage letter

Medicaremoderate

Request for Employment Information

CMS-L564 · CMS

Employer verification of group health plan coverage dates. Required alongside CMS-40B when using a Special Enrollment Period after employer coverage ends.

Form Details

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Where to Submit This Form

📬

Mail to your local SSA office with CMS-40B

https://secure.ssa.gov/ICON/main.jsp

Submit together with your CMS-40B (Medicare Part B enrollment form).

🏢

In person at local SSA office

https://secure.ssa.gov/ICON/main.jsp

Filing Deadline

Within 8 months of losing employer group health coverage (or stopping work, whichever comes first).

Required Attachments

📎 Must be completed and signed by your employer or former employer
📎 CMS-40B (Application for Enrollment in Medicare Part B)
📎 Proof of prior coverage dates (insurance card, coverage letter)

Processing Time

2-4 weeks after SSA receives both CMS-L564 and CMS-40B.

What Happens Next

SSA will process your Special Enrollment Period request. If approved, Part B coverage typically starts the first day of the month after enrollment.

Tips for This Form

✓ This form PROVES you had employer coverage — without it, you may face late enrollment penalties
✓ Have your employer's HR department fill out Section B
✓ If your employer no longer exists, contact the plan administrator or insurance company for a coverage letter

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