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Form CMS-L564, Request for Employment Information
What is CMS-L564?
CMS-L564 is the Medicare Request for Employment Information from the Centers for Medicare & Medicaid Services (CMS).
It shows proof of group health plan coverage based on current employment for Medicare enrollment.
How CMS and Social Security accept Form CMS-L564
The person signing up for Medicare Part B completes Section A, and the employer completes Section B.
If your employer cannot complete Section B, Social Security says to complete it as best you can without the employer's signature and to send other proof of coverage.
CMS instructs applicants to mail or fax the completed form with CMS-40B to their local Social Security office.
For people who already have Part A and are age 65 or older, SSA offers an online Part B application during a Special Enrollment Period when they are ending an employer group health plan.
The CMS form page provides instructions for completing CMS-L564.
The blank on this page
The blank is marked “Form CMS-L564 (Revised 03/2025)”.
You can fill in this blank in the PDFLiner editor.
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Fillable online Form CMS-L564