CMS-L564 Request for Employment Information

Medicare Form Summary

You’ll need the CMS-L564 form to verify employment and employer group health plan coverage. If you delayed enrolling in Medicare because you had coverage through your job, use this form to enroll during your Special Enrollment Period (SEP). In order to qualify for the SEP, you must have had group health plan coverage within the last 8 months through your or your spouse’s employment.

What you’ll need:
• Your basic information and employer name
Other important information:
• Your employer will need to complete the second half of the form with your employment dates and dates of your group health plan coverage.

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