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How do I get a CMS-L564 form?

Phone: Call Social Security at 1-800-772-1213. En espaol: Llame a SSA gratis al 1-800-772-1213 y oprima el 2 si desea el servicio en espaol y espere a que le atienda un agente. In person: Your local Social Security office. For an office near you check .ssa.gov. CMS-L564: Request for Employment Information CMS (.gov) cms-l564-request-employment CMS (.gov) cms-l564-request-employment

What is the proof of employment form for Medicare?

The Request for Employment Information: Form CMS-L564 The Form CMS-L564 is used for proof of group health plan coverage based on current employment (i.e., active coverage), which is needed to process the Medicare enrollment application.

What is OMB 0938 0787 Request for employment information?

OMB 0938-0787 This information is needed to determine whether an individual is eligible to enroll in Medicare Part B or Premium Part A under the provisions of section 1837(i) of the Social Security Act (The Act) and/or qualify for a reduction in the premium amount under the provisions of section 1839(b) of the Act. Request for Employment Information (CMS-R-297/CMS-L564) omb.report omb omb.report omb

What forms are needed for Medicare Part B?

Fill out the Application for Enrollment in Medicare Part B (CMS-40B) (PDF). If you are applying during the Special Enrollment Period, also fill out the Request for Employment Information (CMS-L564) (PDF).

How do I get CMS forms?

Hard copy forms may be available from Intermediaries, Carriers, State Agencies, local Social Security Offices or End Stage Renal Disease Networks that service your State. CMS Forms CMS (.gov) medicare forms-notices cm CMS (.gov) medicare forms-notices cm

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