CMS-L564 Form: How to Fill Out the L564 Step by Step

Intro

If you're signing up for Medicare Part B after age 65 and you're leaving a group health plan tied to your own current job or your spouse's current job, you'll need to know how to correctly complete Form CMS-L564. In the next few minutes, we'll walk through the form step by step so you can submit it without errors.

Step 1: Review the Form L564 instructions

Form L564 step-by-step instructions for completion, divided into Section A for Medicare applicants to provide personal and employer details and Section B for employers to confirm group health plan coverage, hours bank arrangements, and signed certification details.

Special Enrollment Period basics

A quick refresher: your Special Enrollment Period applies when you're past your seven-month Initial Enrollment Period for Medicare and you're leaving a group health plan through an employer — either your own or your spouse's. To avoid a Part B late enrollment penalty, you must submit your application either while you're still covered under that employment-based group plan, or within eight months after your coverage or employment ends.

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In this situation, you'll need to submit two forms to your local Social Security office: Form CMS-40B and Form CMS-L564. Both are available for download at ssa.gov/forms.

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Form L564 overview

Form L564, the Request for Employment Information, is divided into two parts — Section A and Section B. Most of the delays we see happen at a handful of predictable spots, so let's go through the form carefully and get each one right.

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One thing to know up front: Social Security requires a separate form for every person enrolling in Part B. So if a married couple is applying at the same time, each spouse needs their own completed L564 — even the spouse who isn't working. That's because the non-working spouse's coverage comes through the working spouse's job, and Social Security still needs to verify the coverage dates for both people individually.

Step 2: Identify Section A for the applicant

Form titled 'Request for Employment Information' with Section A outlined in red, to be completed by individuals signing up for Medicare Part B, containing fields for employer's name, date, employer's address including city, state, and zip code, applicant's name and Social Security number, and employee's name and Social Security number. — Section A

Step 3: Identify Section B for the employer

A form section titled 'SECTION B: To be completed by Employers' with fields for employer group health plans and hours bank arrangements, including checkboxes for Yes/No answers, date input boxes for coverage periods, employee work dates, and signature and date signed fields for company official. — Section B

Section A: completed by the applicant

Section A is meant to be filled out by the person enrolling in Medicare Part B. In practice, employers often complete this section for the applicant — but you're free to fill it in yourself, either before handing the form to your employer or after you get it back.

Step 4: Begin the applicant section

Form titled 'Request for Employment Information' from the Department of Health and Human Services and Centers for Medicare & Medicaid Services, used to collect details for Medicare Part B enrollment. Section A, outlined in red, is to be completed by the individual and includes fields for Employer's Name, Date, Employer's Address, City, State, Zip Code, Applicant's Name, Applicant's Social Security Number, Employee's Name, and Employee's Social Security Number. Section B, partially visible below, is for employers to complete for group health plans, including questions about coverage status and dates.

Field 1 is your employer's name.

Step 5: Enter the employer's name in Field 1

Request for Employment Information form from the Department of Health and Human Services for Medicare Part B enrollment showing sections for employer and applicant details, including fields for names, addresses, social security numbers, and employer group health plan coverage information.

Field 2 is the date you're completing Section A.

Step 6: Enter the completion date in Field 2

Form titled 'Request for Employment Information' from the Department of Health and Human Services Centers for Medicare & Medicaid Services, with sections for individual and employer to complete, including fields for employer's name and address, date, applicant and employee names, social security numbers, and employer group health plan coverage details.

Field 3 is the employer's address.

Step 7: Enter the employer's address in Field 3

Fields 4 through 7 are where most of the confusion happens.

Step 8: Identify the applicant and employee fields

Medicare Part B Request for Employment Information form with sections for individual and employer to fill. Includes fields for employer's name, date, address, applicant's name and Social Security number, employee's name and Social Security number, and employer group health plan coverage questions.

Field 4 is the applicant's name — the person enrolling in Medicare.

Step 9: Enter the applicant's name in Field 4

A partially filled paper form titled 'Request for Employment Information' from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. Section A is for individuals signing up for Medicare Part B, requesting employer's name, date, employer's address, applicant's name, social security number, employee's name, and social security number. Section B is for employers, including questions about employer group health plan coverage and dates of coverage.

Field 5 is the applicant's Social Security number.

Step 10: Enter the applicant's Social Security number in Field 5

A partially filled form titled 'Request for Employment Information' from the Department of Health and Human Services Centers for Medicare & Medicaid Services. Section A is to be completed by the individual signing up for Medicare Part B, with fields for employer's name, date, address, and applicant and employee names and Social Security numbers. Section B is for employers to complete about employer group health plans, with yes/no checkboxes and date fields for coverage details.

Field 6 is the employee's name, which may or may not be the same person named in Field 4.

Step 11: Enter the employee's name in Field 6

Form titled 'REQUEST FOR EMPLOYMENT INFORMATION' from the Department of Health and Human Services for Medicare Part B. Section A is to be filled by individuals signing up for Medicare Part B, requesting employer's name and address, date, applicant's name, social security number, employee's name and social security number. Section B is for employers to complete with questions about employer group health plans coverage, including coverage dates and status.

Step 12: Enter the employee's Social Security number in Field 7

Request for Employment Information form from Department of Health and Human Services for Medicare Part B. Section A for individual to fill employer's name, date, employer's address, city, state, zip code, applicant's name and SSN, employee's name and SSN. Section B for employers about employer group health plans with yes/no checkboxes for coverage questions.

If you're both the Medicare applicant and the employee whose job the coverage is based on, Fields 6 and 7 should simply repeat what you entered in Fields 4 and 5.

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But if the applicant is a spouse who's a dependent on someone else's group plan, the applicant and the employee are two different people — meaning the names and Social Security numbers in Fields 4/5 and 6/7 won't match.

Step 13: Check the applicant and employee details for spousal coverage

Form titled 'Request for Employment Information' from the Department of Health and Human Services for Medicare Part B enrollment. Section A is for individuals to fill employer details, date, applicant name, applicant's Social Security number, employee name, and employee's Social Security number. Section B is for employers to complete, asking about employer group health plan coverage with yes/no checkboxes and date fields.

That's the whole of Section A. The one thing to double- and triple-check is that the applicant's identity and the employee's identity are entered correctly and in the right fields.

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Section B: completed by the employer

Section B must be completed by the employer — this part isn't optional for them to skip.

Step 14: Have the employer complete Section B

Form section titled 'SECTION B: To be completed by Employers' with two parts: For Employer Group Health Plans ONLY and For Hours Bank Arrangements ONLY, with questions about applicant coverage dates, employment dates, coverage status, and hours bank arrangements, including checkboxes for Yes and No and spaces to fill dates in mm/yyyy format.

Field 1 needs to be marked "Yes." If it isn't, Social Security can't process the form.

Step 15: Confirm employer group health coverage in Field 1

Form section B for employers with fields about employer group health plans and hours bank arrangements, including yes/no checkboxes and date fields to indicate coverage status and employment dates.

Field 2 trips people up more than any other line on the form. It asks for the date the applicant's coverage began — but the wording is easy to misread. What it's actually asking for is the month and year the applicant's group health coverage originally started with this employer, not the date of the most recent plan renewal.

Step 16: Enter the original coverage start date in Field 2

Form section labeled 'SECTION B: To be completed by Employers' with questions about employer group health plans and hours bank arrangements, including checkboxes for yes/no answers and blank fields for dates in mm/yyyy format.

This is the most common employer error: entering something like January 1 of the current year because that's when the plan last renewed, rather than the true original start date of coverage.

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Related tip: if you've had employer coverage through more than one employer since turning 65, you'll need a separate L564 for each one. As long as the combined coverage periods reach back to at least your 65th birthday with no gap longer than eight months, you're still fine.

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Field 3 asks whether the coverage has already ended as of the date the form is being filled out.

Step 17: Indicate whether coverage has ended in Field 3

Excerpt of a form section titled 'SECTION B: To be completed by Employers' with subsections for Employer Group Health Plans and Hours Bank Arrangements, containing questions about applicant coverage dates, coverage status, employment dates, and hours bank usage, with checkboxes and fill-in date fields.

If it has, mark "Yes" and then complete Field 4 with the month and year coverage ended. If coverage is still active as of the date the form is completed, mark "No," and Field 4 can be left blank or marked N/A.

Step 18: Complete Field 4 if coverage has ended

Form section titled 'SECTION B: To be completed by Employers' with fields for Employer Group Health Plans and Hours Bank Arrangements, including questions about applicant coverage, coverage start and end dates, employment dates, and hours bank details, with several date fields formatted as mm/yyyy and checkboxes for Yes or No responses.

Step 19: Review the coverage end date fields

Section B of a form to be completed by employers, focusing on employer group health plans and hours bank arrangements, with checkboxes for yes or no answers and spaces to input dates in mm/yyyy format, highlighted are questions about whether coverage has ended and the date it ended.

Step 20: Record the employment dates in Field 5

Field 5 asks when the employee started working for the employer. The "From" date must always be filled in — again, this may require a separate form per employer if you've had more than one job since turning 65.

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From there, you'll complete either the "To" date or the "Still Employed" date, but never both. If employment has ended, enter the separation date in the "To" field. If the employee is still actively working there as of the date the form is completed, enter the current month and year under "Still Employed" instead.

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Step 21: Review whether hours bank arrangements apply

Field 6 and the entire "Hours Bank Arrangement" section apply only in less common situations, so we won't cover them in detail here.

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Step 22: Have the employer sign and date the form

Finally, the bottom of Section B is where the employer's representative signs, dates the form, and provides their job title and phone number.

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Wrap-up

It's a short form, but a few specific fields — especially the original coverage start date in Field 2 — are where most delays happen. Once you understand what's actually being asked, filling it out correctly is straightforward.

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With Form L564 completed alongside your already-finished Form CMS-40B, you're ready to enroll in Medicare Part B without triggering a late enrollment penalty when leaving a group health plan.

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Step 23: Submit both completed forms to Social Security

The final step is to bring both completed forms to your local Social Security office in person to apply for your desired Part B start date. Plan to do this within the three months before the date you want coverage to begin.

How to Complete Form CMS-L564 (Request for Employment Information)

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