CMS-L564, the "Medicare Request for Employment Information," is your proof that you had health coverage from a current job. It goes together with CMS-40B when you sign up for Part B during the Special Enrollment Period. The form has two short sections. You fill in Section A. Your employer fills in Section B.
The current version is marked Form CMS-L564 (Revised 03/2025), OMB No. 0938-0787, expiring 03/2028. Older copies still float around online, so check the date printed at the bottom of the page before you start.
Who fills out what
- Section A: you, the person signing up for Part B.
- Section B: the employer. Social Security's manual says the group health plan itself can also complete it. Section B is the actual evidence of your coverage (POMS HI 00805.295).
If you're self-employed, you still complete Section A, but the health plan completes Section B, not you (POMS HI 00805.290).
Section A: your part
| Field | What to write |
|---|---|
| Applicant's name | Your name. You are the "applicant," the person signing up for Part B. |
| Applicant's Social Security Number (SSN) | Your SSN. Write it in by hand. |
| Employee's name (if different from applicant) | Leave blank if the job is yours. If your coverage comes through your spouse's job, write your spouse's name. |
| Employee's SSN (if different) | Only if it's your spouse's job: your spouse's SSN, by hand. |
| Employer's name | The employer whose plan covers you (yours or your spouse's). |
| Employer's address, City, State, ZIP code | That employer's mailing address. |
Why the SSN lines are blank in our kit
After65 Forms never asks for your Social Security number or Medicare number. If you use our kit, the rest of Section A is typed in for you, and you write the SSNs in by hand before you hand the form to your employer.
More than one employer? If you were covered through more than one employer's plan since you turned 65, Social Security needs evidence from each one (POMS HI 00805.295). Fill out one form per employer.
Check your Part B Special Enrollment Period in 2 minutes. Start the free Part B check →
Section B: the employer's part
Section B has three blocks. Most employers fill in the first and the last.
Block 1: "For Employer Group Health Plans ONLY"
- "Is (or was) the applicant covered under an employer group health plan?" Yes or No.
- "If yes, give the date the applicant's coverage started (mm/yyyy)." The month and year your coverage began, even if it's your spouse's job. This date matters: you need coverage going back to your first month of Part B eligibility.
- "Did the coverage end?" Yes or No. If yes, the month and year it ended (mm/yyyy). If you're still covered, the answer is No.
- "When did the employee work for your company?" From and To (mm/yyyy), plus "Still employed?" Yes or No. The "employee" is whoever holds the job: you, or your spouse.
- The large group health plan line ("If you're a large group health plan and the applicant is disabled..."). This is for people under 65 who have Medicare because of a disability. The large-plan rule doesn't apply to people who have Medicare because of age (POMS HI 00805.266), so this line normally stays blank.
These end dates show when your 8-month clock starts: the month after your work or your coverage ended, whichever came first.
Block 2: "For Hours Bank Arrangements ONLY"
This is for union members whose coverage is paid from an hours bank. It asks whether you are (or were) covered under an hours bank arrangement, whether you have hours left in reserve, and the month the reserve hours ended or will be used up. For these members, the last day of current employment is the date the reserve hours run out (POMS HI 00805.278). Most employers skip this block. See retiree coverage and Part B for how hours banks work.
Block 3: "All Employers"
- Signature of company official
- Date signed (mm/dd/yyyy)
- Title of company official
- Phone number
No wet signature needed
Social Security says Section B does not need a handwritten signature. An electronic signature, stylus signature or rubber stamp is acceptable (POMS HI 00805.295). A remote HR team can sign it digitally and send it back.
Notice the two date formats: coverage and work dates are month and year (mm/yyyy), but the signature date is a full date (mm/dd/yyyy).
Tips for getting HR to complete it
- Fill in Section A first, then send HR the whole form, both pages.
- Say exactly what you need: "Please complete and sign Section B of CMS-L564 (Revised 03/2025)."
- Ask for month and year on every date. Social Security needs to see when coverage started and, if it ended, when.
- Ask them to return it to you. The form says to mail or fax it together with your CMS-40B, so it should come back to you first.
- Start early. Medicare.gov suggests signing up about a month before your coverage ends. Give HR time before that.
- Check the dates against what you put on your CMS-40B. They should match.
- Keep a copy of the signed form.
If HR won't sign, is slow, or the company has closed, you have other options. See what to do if your employer won't sign CMS-L564.
Where the form goes
Mail or fax the completed L564 together with your CMS-40B to your local Social Security office. You can find the office at SSA.gov/locator. If you apply online instead, Social Security's Medicare booklet says to upload your proof of coverage as part of the application (SSA Publication 05-10043). All the options are in how to submit CMS-40B and CMS-L564.