Form Cms-L564 - Request For Employment Information
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1U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES
OMB NO. 0938-0787
REQUEST FOR EMPLOYMENT INFORMATION
From:
Telephone Number:
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/yyyy)
(mm/yyyy)
(mm/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 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 (04/10)
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Parent category: Medical