If you are already enrolled in Medicare Part A and you would like to enroll in Part B under the Special Enrollment Period (SEP), you can apply online at Apply for Medicare Part B Online during a Special Enrollment Period. You can upload your application and documents that verify your group health plan coverage through your employer. Show
You can also fax or mail your completed CMS-40B, Application for Enrollment in Medicare – Part B (Medical Insurance) and the CMS-L564, Request for Employment Information enrollment forms and evidence of employment to your local Social Security office. If you have questions, please contact Social Security at 1-800-772-1213 (TTY 1-800-325-0778). Note: When completing the forms CMS-40B and CMS-L564:
Sign up for Part B
REQUEST FOR EMPLOYMENT INFORMATIONWHAT IS THE PURPOSE OF THIS FORM?In order to apply for Medicare in a Special Enrollment Period, you must have or had group health plan coverage within the last 8 months through your or your spouse’s current employment. People with disabilities must have large group health plan coverage based on your, your spouse’s or a family member’s current employment. 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. HOW IS THE FORM COMPLETED?
WHAT DO I DO WITH THE FORM?Fill out Section A and take the form to your employer. Ask your employer to fill out Section B. 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. GET HELP WITH THIS FORM
Form CMS-L564 (CMS-R-297) (09/16) DEPARTMENT OF HEALTH AND HUMAN SERVICES Form Approved REQUEST FOR EMPLOYMENT INFORMATIONAccording to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information is 0938-0787. The time required to complete this information collection is estimated to average 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, MD 21244-1850. Form CMS-L564 (CMS-R-297) (0 9/1 6) Form Approved STEP BY STEP INSTRUCTIONS FOR FILLING OUT THIS APPLICATIONSECTION A:The person applying for Medicare completes all of Section A.
Once you complete Section A: SECTION B:The employer completes all of Section B. If you’re an employer without an hours bank arrangement, complete the section called “For Employer Group Health Plans ONLY” Is (or was) the applicant covered under an employer group health plan? Please check yes or no if the applicant was covered under your group health plan offered by your company. The applicant may be the employee or another person related to the employee, such as a spouse or family member with disabilities. If your company doesn’t offer a group health plan, please check No. A group health plan is any plan of one or more employers to provide health benefits or medical care (directly or otherwise) to current or former employees, the employer, or their families. If yes, give the date the coverage began. Write the month and year the date the applicant’s coverage began in your group health plan. Has the coverage ended? Check yes or no if the group health plan coverage for the applicant has ended. If yes, give the date the coverage ended. Write the month and year the group health plan coverage ended for the applicant..
If you’re an employer with an hours bank arrangement, complete the section called “For Hours Bank Arrangements ONLY”
All employers need to complete the bottom of Section B.
INSTRUCTIONS: Form CMS-L564 (CMS-R-297) (09/16) |