Summary: Form CMS-L564, Request for Employment Information (formerly HCFA L564), proves group health plan coverage through current employment so a person can sign up for Medicare Part B in a Special Enrollment Period without a late penalty. This guide covers where to download the current form (revised 03/2025, OMB 0938-0787), when it is needed, every field in Section A and Section B, how to submit it with Form CMS-40B online, by fax or by mail, what evidence Social Security accepts if the employer cannot complete it, a Part B late enrollment penalty calculator and FAQs.
Form CMS-L564, Request for Employment Information, proves that you had group health plan coverage through your own or your spouse's current employment, so you can sign up for Medicare Part B in a Special Enrollment Period without a late penalty. You fill out Section A, your employer fills out and signs Section B, and you send it with Form CMS-40B to Social Security. Download the current form from CMS: CMS-L564 in English (PDF) or in Spanish (PDF).
The form was called HCFA L564 before the Health Care Financing Administration was renamed the Centers for Medicare & Medicaid Services. Below: the form at a glance, when you need it, every field in Sections A and B, how to submit it, what to do if your employer can't complete it, a penalty calculator and FAQs.
CMS-L564 at a glance
| Item | Detail |
|---|---|
| Official name | Request for Employment Information (CMS-L564) |
| Used for | Proving group health plan coverage through current employment for a Part B Special Enrollment Period |
| Who completes it | Applicant completes Section A; employer completes and signs Section B |
| Filed with | Form CMS-40B, Application for Enrollment in Medicare Part B |
| Where to send it | Online through Social Security, or by mail or fax to your local Social Security office |
| Current version | Revised 03/2025; OMB No. 0938-0787, expires 03/2028 |
| Time to complete | About 15 minutes, per CMS |
| Languages | English and Spanish |
Sources: CMS form page and the form itself.
When you need the CMS-L564
You need it when you delayed Part B because you or your spouse had job-based group health coverage, and you are now signing up after your Initial Enrollment Period. CMS says you must have, or have had, group health plan coverage through current employment within the last 8 months (CMS).
- 8-month window: your Special Enrollment Period starts when you stop working, even if you choose COBRA or other non-Medicare coverage (Medicare.gov).
- COBRA does not extend it: COBRA coverage is not based on current employment, so it does not restart or extend the 8 months.
- Not accepted as proof: Individual Coverage Health Reimbursement Arrangements (ICHRAs) do not qualify for this Special Enrollment Period, and a Part D creditable coverage letter is not proof of group health plan coverage (SSA POMS).
- Timing tip: to have Part B start when job coverage ends, sign up the month before you or your spouse retire.
How to fill out Section A (applicant)
| Item | Field | Tip |
|---|---|---|
| 1 | Applicant's name | Use the name on your Medicare or Social Security record |
| 2 | Applicant's Social Security Number | Your own SSN |
| 3 | Employee's name, if different | Enter your spouse's name if the coverage came through their job |
| 4 | Employee's SSN, if different | Your spouse's SSN when item 3 is filled in |
| 5 | Employer's name | The employer's legal business name |
| 6–7 | Employer's address, city, state and ZIP | Use the HR or benefits office address so Section B reaches the right person |
How the employer fills out Section B
| Item | Question | Format |
|---|---|---|
| 1 | Is (or was) the applicant covered under an employer group health plan? | Yes or No |
| 2 | Date coverage began | mm/yyyy |
| 3–4 | Did the coverage end? If yes, the end date | Yes or No; mm/yyyy |
| 5 | Dates of employment and whether the person still works there | mm/yyyy from and to |
| 6 | For disabled applicants on a large group health plan: months the plan was primary | Months |
| 7–9 | Hours Bank Arrangement coverage, hours left in reserve and when they end | Yes or No; mm/yyyy |
| 10–11 | Company official's signature, date, title and phone number | mm/dd/yyyy for the date |
If coverage came from more than one employer during the period, ask each employer to complete its own Section B. Employers that use an employer of record (EOR) provider, such as Remote People, can usually get the coverage and employment dates from that provider; see this overview of EOR services.
How to submit CMS-L564 with CMS-40B
- Complete both forms: CMS-40B (Part B application) and CMS-L564 with Sections A and B filled in.
- Choose your start date: in the remarks section of CMS-40B, write "I want Part B coverage to begin (MM/YY)".
- Submit: apply online through Social Security, which requires an email address for the electronic signature, or mail or fax both forms to your local Social Security office.
- Add evidence if needed: if Section B is incomplete, include the alternative evidence listed below.
- Keep copies of everything you send.
Source: Social Security: sign up for Part B online, by fax or by mail. Social Security warns that incorrect or incomplete documents can delay or reject the application. For the full sign-up process, see how to apply for Medicare.
If your employer can't complete the form
If the employer cannot complete Section B, for example because the company closed, Social Security accepts other evidence of group health plan coverage (SSA POMS HI 00805.295):
| Document | What it should show |
|---|---|
| Income tax returns | Health insurance premiums paid |
| W-2 forms | Pre-tax medical contributions |
| Pay stubs | Health insurance premium deductions |
| Health insurance cards | A policy effective date |
| Explanations of benefits | Claims paid by the group health plan |
| Statements or receipts | Payment of health insurance premiums |
The evidence should link the coverage to the employer or plan and show when coverage based on current employment began and, if it did, when it ended.
Part B late enrollment penalty calculator
Missing the Special Enrollment Period can mean a permanent penalty: 10% of the standard premium for each full 12-month period you could have had Part B but didn't. In 2026, a 2-year gap adds $40.60 a month to the $202.90 standard premium (Medicare.gov).
Part B late enrollment penalty calculator
Estimate the Part B penalty if a Special Enrollment Period is missed. The penalty is 10% of the standard premium for each full 12-month period without Part B or qualifying job-based coverage. The default premium is the 2026 standard amount of $202.90.
The penalty usually lasts as long as you have Part B and is recalculated each year as the standard premium changes. Medicare rounds the penalty to the nearest $0.10. Income-related surcharges are not included. This tool does not store any data.
Common CMS-L564 mistakes
- Section B left unsigned or without the official's title and phone number.
- Coverage dates in the wrong format; Section B uses month and year (mm/yyyy).
- COBRA or retiree coverage listed as coverage through current employment.
- Sending CMS-L564 without CMS-40B, or without a requested start date.
- Waiting past the 8-month window while the employer completes the form. Submit with alternative evidence instead.
Why therapy clinics should know this form
Patients who move from job-based coverage to Medicare often ask the front desk for help, and a gap in Part B shows up as a denied claim. Checking coverage at each visit with real-time eligibility catches the change early. See also Medicare coverage for physical therapy.
Frequently asked questions
What is the CMS-L564 form?
Form CMS-L564, Request for Employment Information, is a Medicare form that shows you had group health plan coverage through your or your spouse's current employment. It lets you sign up for Part B in a Special Enrollment Period without a late penalty.
Where can I download the CMS-L564 form?
From CMS: the English PDF and the Spanish PDF. The current version was revised in 03/2025 and expires 03/2028.
Who fills out the CMS-L564?
You complete Section A. Your employer, or your spouse's employer, completes and signs Section B.
Where do I send the CMS-L564?
Send it with Form CMS-40B to Social Security, online or by mail or fax to your local Social Security office. Do not send it to Medicare or your insurer.
Can I submit the CMS-L564 online?
Yes. Social Security lets you complete Part B enrollment online and sign electronically, which requires an email address.
What if my employer won't or can't fill out Section B?
Send other evidence instead, such as tax returns showing premiums, W-2s with pre-tax medical contributions, pay stubs with premium deductions, insurance cards with an effective date, explanations of benefits or premium receipts.
Is HCFA L564 the same as CMS-L564?
Yes. HCFA was the former name of the Centers for Medicare & Medicaid Services, so older references to Form HCFA L564 mean the same Request for Employment Information.
What happens if I miss the 8-month Special Enrollment Period?
You may have to wait for the General Enrollment Period and pay a Part B late penalty of 10% of the standard premium for each full 12-month period you went without coverage. Use the calculator above to estimate it.
This guide is general information, not legal or benefits advice. Check current forms and rules with Social Security and Medicare.
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