Fill Out Form CMS-L564 in 2026
Your employer certifies your group health coverage dates here, giving you the proof needed to enroll in Medicare during a Special Enrollment Period.
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How to fill out a CMS-L564 Form
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Open the form
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Fill in your details
Enter the employer's name, applicant's Social Security number, and coverage dates.
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What is a CMS-L564 Form?
Form CMS-L564, Request for Employment Information, is a Medicare form you and your employer fill out together. You complete Section A, then your employer completes Section B to confirm your group health plan coverage based on current employment. This proof lets you enroll in Medicare during a Special Enrollment Period after job-based coverage ends. You send it with your Application for Enrollment in Medicare (CMS-40B) to your local Social Security office, avoiding late enrollment penalties.
Key Takeaways
- Form CMS-L564 proves group health coverage
- Employer completes Section B of the form
- Submit it with CMS-40B to Social Security
What is a CMS-L564 Form used for?
Employers use this form to confirm your health coverage while you were working, information Medicare needs to process your enrollment. Form CMS-L564, Request for Employment Information, supports several steps in that process:
- Proves you had group health coverage based on current employment
- Documents eligibility for a Special Enrollment Period, showing no coverage gap over 8 months since Part B eligibility
- Gets submitted with Form CMS-40B to the Social Security office to complete Part B enrollment
- Lets your employer certify your coverage dates and employment details
What information is required on a CMS-L564 Form?
Employer's Name and Address
Enter your employer's name, the current date, and the employer's mailing address.
Applicant's Name and Social Security Number
Write your full name and Social Security number as the Medicare applicant.
Employee's Name and Social Security Number (if different from applicant)
List the employee's name and Social Security number if coverage comes through another person.
Is (or was) the applicant covered under an employer group health plan?
Mark yes or no and enter the coverage or enrollment dates for the group health plan.
Did the coverage end?
Mark yes or no and give the exact date the group health coverage ended, if applicable.
Employment dates and group health plan coverage confirmation
Employer enters the employment start and end dates and the group health coverage period.
Employer certification of coverage
Employer confirms coverage start and end dates, verifying no gap exceeds eight consecutive months.
Signature and Date (Employer official)
An authorized employer official signs and dates Section B to certify the information given.
When is a CMS-L564 Form due?
There's no fixed calendar deadline. You submit Form CMS-L564 alongside your CMS-40B Medicare application when you enroll in Part B during a Special Enrollment Period, after losing employer group health coverage. Timing depends on your situation: your employer must show coverage lasting through no more than 8 months before you file. Inside your Initial Enrollment Period, you won't need this form at all.
Complete your CMS-L564 Form
Open Form CMS-L564 here, fill in your employment details, and download the completed copy to keep on hand.
When is a CMS-L564 not required?
You can skip the form if you're enrolling during your Initial Enrollment Period instead of a Special Enrollment Period, since no proof of employer coverage applies then. It's also unnecessary if your coverage gap ran longer than 8 consecutive months, or if your employer can't complete it — Social Security will then accept W-2s, pay stubs, insurance cards, or benefit letters instead.
What does a CMS-L564 form look like
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