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The document is a Medicare and Medicaid employment information request form (CMS-L564) that outlines the process for individuals to apply for Medicare during a Special Enrollment Period. It requires the applicant to provide details about their employer and health coverage, which must be verified by the employer. The completed form is then submitted to the local Social Security office as part of the Medicare enrollment application.

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Where do I get CMS L564?

You can find your local Social Security office by clicking \u201cSSA Office Locator\u201d under the \u201cRelated Links\u201d section below. Your employer doesn't need to sign Section B of the CMS L564 form. State \u201cI want Part B coverage to begin (MM/YY)\u201d in the remarks section of the CMS 40B form or the online application.

What is a CMS 1564 form?

CMS 1564. Form Title. MONTHLY CARRIER REPORT ON MEDICARE SECONDARY PAYER SAVINGS.

How do I submit Medicare Part B?

Fill out Form CMS-40B (Application for Enrollment in Medicare Part B). Send the completed form to your local Social Security office by fax or mail. Call 1-800-772-1213. TTY users can call 1-800-325-0778.

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What is a CMS form for?

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.

Where do I get CMS-L564?

You need to get the completed form from your employer and include it with your Application for Enrollment in Medicare (CMS-40B). Then you send both together to your local Social Security office. Find your local office here: www.ssa.gov.

What is a CMS 40B form?

CMS 40B. Form Title. Application for Enrollment in Medicare - Part B (Medical Insurance) Revision Date.

Can I fill out form CMS 40B online?

You can apply online or you can mail your completed CMS 40B, Application for Enrollment in Medicare - Part B (Medical Insurance) to your local Social Security office.

Can form CMS-L564 be submitted online?

You can complete form CMS-40B (Application for Enrollment in Medicare \u2013 Part B [Medical Insurance]) and CMS-L564 (Request for Employment Information) online. You can also fax the CMS-40B and CMS-L564 to 1-833-914-2016; or return forms by mail to your local Social Security office.

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