Form CMS-L564 (2016)


(4.5 / 5) 32 votes
Form CMS-L564 (2016) - Thumbnail

Get your Form CMS-L564 (2016) in 3 easy steps

  • 01 Fill and edit template
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How to Redact and Fill Out Form CMS-L564 2016 Online

Form CMS-L564, also known as the Request for Employment Information, is a form used by the Centers for Medicare & Medicaid Services (CMS) to verify an individual's employment status and eligibility for health insurance benefits. To redact and fill out the form CMS-l564 request for employment information online, you can follow these steps:

  1. Download the form CMS-l564. 
  2. Open the CMS-L564 printable form in a PDF editor, such as Adobe Acrobat or Foxit PhantomPDF.
  3. Use the redaction tool to black out any sensitive information, such as Social Security numbers or personal addresses.
  4. Fill out the CMS l564 form with the required information, including your name, employer's name and address, and the dates of your employment.
  5. Save the completed cms l564 form and download on your computer or device.
  6. Submit the form online through the CMS website or by mail to the address provided on the form.

What Should Form CMS-L564 2016 Include

Form Cms-l564 Screenshot

Form CMS-L564 should include the following information:

  • The individual's name and date of birth
  • The individual's Social Security number (SSN)
  • The individual's current address and phone number
  • The name of the individual's current employer, including their address and phone number
  • The dates of the individual's employment with their current employer
  • The individual's job title and job duties
  • Signature of the individual or authorized representative

When to Request a Form CMS-L564

Form CMS-L564 should be requested when:

  • An individual is applying for Medicare Part A and/or Part B, and they wish to continue working past their 65th birthday.
  • An individual is applying for a Special Enrollment Period (SEP) due to a change in employment status, such as loss of employer-sponsored coverage, or change in job status.
  • An individual is applying for Medicare due to disability and they are still employed.
  • An individual is applying for Medicare and they have group health plan coverage based on current employment.
  • An individual is requesting to enroll in Part B outside of the Initial Enrollment Period, and they are still working.

Also, it is important to note that the form should be requested as soon as possible, as the CMS will require it to process the application and determine the individual's eligibility for benefits.

Fillable online Form CMS-L564 (2016)
(4.5 / 5) 32 votes
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