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2 2 Verify Existing Employee using Form I-9CMS-L564: Request for Employment InformationCMSBenefit Ve

2 2 Verify Existing Employee using Form I-9CMS-L564: Request for Employment InformationCMSBenefit Ve 2026

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The document is an Employer Benefit Verification Form for retirees who were hired on or after August 1, 2003, detailing the requirements for health benefits under the Retired Employees Health Program (REHP). It specifies that spouses of REHP retirees must have primary health coverage through their own employer to qualify for secondary coverage under REHP. The form requires information from both the retiree and the spouse's employer to verify eligibility and enrollment in health insurance.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the Commonwealth retiree’s name in the designated field. This is essential for identifying the retiree associated with the health benefits.
Next, input the last four digits of the retiree’s Social Security Number and their date of birth in mm/dd/yyyy format. This information helps verify identity and eligibility.
Fill in the spouse’s name and date of birth, ensuring accuracy as this data is crucial for benefit verification.
Indicate whether your spouse is employed full-time or part-time, or if they are retired. This section determines their eligibility for health insurance coverage.
The retiree must sign at the bottom to validate the information provided before submission.
An authorized representative from the spouse's employer should complete their section, including company name and eligibility details regarding health insurance.

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Versions	Form popularity	Fillable & printable
2023	4.3 Satisfied (33 Votes)
2022	4.8 Satisfied (36 Votes)
2019	4.2 Satisfied (57 Votes)
2016	4.6 Satisfied (36 Votes)
2015	4 Satisfied (58 Votes)

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What are the different types of CMS forms?

CMS Forms List Form #Form Title CMS 10003-NDMCP NOTICE OF DENIAL OF MEDICAL COVERAGE/PAYMENT (INTEGRATED DENIAL NOTICE) CMS 10036 Inpatient Rehabilitation Facility-Patient Assessment Instrument CMS 10055 SKILLED NURSING FACILITY ADVANCED BENEFICIARY NOTICE Form # CMS 10069 Medicare Waiver Demonstration Application6 more rows Sep 10, 2024

What is the L564 request for employment information?

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 is proof of coverage for Medicare?

Medicare plan , your plan will send you an Evidence of Coverage (EOC) each year, usually in the fall. The EOC gives you details about what the plan covers, how much you pay, and more.

What is form 564?

How to Fill Out Medicare Forms CMS-L564 and CMS 40-B. Two essential forms often come into play when enrolling in Medicare Part B: the CMS L-564 (Request for Employment Information) and the CMS 40-B (Application for Enrollment in Medicare Part B).

How do I prove creditable coverage for Medicare?

A person will usually receive a Notice of Creditable Coverage in the mail every September, and they should keep this as proof should they later apply for Medicare coverage. If a person wishes to enroll in Medicare after their creditable coverage ends, they may be eligible for the Special Enrollment Period.

2 2 Verify Existing Employee using Form I-9CMS-L564: Request for Employment InformationCMSBenefit Ve 2026

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