Form Cms-L564 - Request For Employment Information, Medicare True/false/multiple Choice Quiz Etc.

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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES
OMB NO.0938-0787
REQUEST FOR EMPLOYMENT INFORMATION
From:
Telephone No.
Social Security Administration
Employer’s Name and Address
Date:
Employee’s Name:
Employee’s Social Security Number:
Claimant’s Name:
Claim Number:
Dear Sir/Madam:
We need the following information regarding the above claimant. Please answer the questions below, sign and date this
letter and return it in the enclosed envelope.
You may call__________________________________________________ at the above telephone number if you have
any questions.
Sincerely,
Office Manage
r
1. Is (or was) the claimant covered under an Employer Group Health Plan?
Yes _______
No _______
2. If yes, give the original date the coverage began. ________________
(mm/yyyy)
3. Has the coverage ended?
Yes _______
No _______
4. If yes, give the date the coverage ended. _________________
(mm/yyyy)
5. When did the employee work for your company?
From ________________
To _________________
Still Employed __________
(mm/dd/yyyy)
(mm/dd/yyyy)
Signature and Title of Company Official
Date
Telephone Number
According 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 any
comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, N2-14-26, Baltimore,
Maryland 21244-1850.
FORM CMS-L564 (4-2000)

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