Request for Employment Information (CMS-R-297 2025

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The document is a Request for Employment Information form from the Centers for Medicare & Medicaid Services, required for individuals applying for Medicare during a Special Enrollment Period. It outlines the process for obtaining proof of group health plan coverage through current employment, detailing how to complete the form and where to submit it. The form must be filled out by both the applicant and their employer, providing necessary information about health coverage and employment dates.

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Click ‘Get Form’ to open it in the editor.
In Section A, fill in your employer’s name, date, and address. Then, provide your name and Social Security Number, along with the employee's name and their Social Security Number if applicable.
Once you complete Section A, hand the form to your employer for them to fill out Section B.
In Section B, your employer will confirm coverage under a group health plan by checking 'Yes' or 'No'. They will also provide dates of coverage and employment details.
Ensure that your employer signs the form at the bottom of Section B and includes their title and phone number.
After both sections are completed, submit this form along with your Medicare Part B application to your local Social Security office.

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Versions	Form popularity	Fillable & printable
2023	4.9 Satisfied (26 Votes)
2020	4.8 Satisfied (234 Votes)
2016	4.3 Satisfied (100 Votes)
2010	4.3 Satisfied (143 Votes)
2000	4 Satisfied (26 Votes)

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Who fills out CMS l564?

This form is used for proof of group health care coverage based on current employment. This information is needed to process your Medicare enrollment application. The employer that provides the group health plan coverage completes the information about your health care coverage and dates of employment.

What happens if my employer wont fill out CMS l564?

When employers wont complete cms-l564 request for employment information, patients can submit alternative documentation including W-2 forms, pay stubs, and health insurance cards as proof of coverage.

How do I get a verification letter for Medicare Part B?

Those requesting employment or salary verification may access THE WORK NUMBER online at using DOLs code: 10915. You may also contact the service directly via phone at: 1-800-367-5690.

What is the penalty for missing Medicare enrollment?

Medicare Part B late enrollment penalty Your monthly premium will increase by 10 percent for every 12-month period you were eligible for Medicare Part B but didnt sign up. In most cases, youll need to pay this extra cost for as long as you have Part B.

What if my employer wont fill out CMS L564?

Make your request in writing The date. Your contact information (name, address, phone number, and email) A subject line, such as RE: Employment verification for [Employee Name] A salutation, such as To whom it may concern: A brief explanation of why youre requesting a job verification letter.

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What happens if a provider opts out of Medicare?

Opt-out providers do not accept Medicare at all and have signed an agreement to be excluded from the Medicare program. This means they can charge whatever they want for services but must follow certain rules to do so. Medicare will not pay for care you receive from an opt-out provider (except in emergencies).