Form Cms-L564 (Cms-R-297) - Request For Employment Information

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Form Approved
CENTERS FOR MEDICARE & MEDICAID SERVICES
OMB No. 0938-0787
REQUEST FOR EMPLOYMENT INFORMATION
WHAT IS THE PURPOSE OF THIS FORM?
WHAT DO I DO WITH THE FORM?
In order to apply for Medicare in a Special Enrollment
Fill out Section A and take the form to your employer. Ask
Period, you must have or had group health plan coverage
your employer to fill out Section B. You need to get the
within the last 8 months through your or your spouse’s
completed form from your employer and include it with your
current employment. People with disabilities must have large
Application for Enrollment in Medicare (CMS-40B). Then you
group health plan coverage based on your, your spouse’s or
send both together to your local Social Security office. Find
a family member’s current employment.
your local office here:
This form is used for proof of group health care coverage
GET HELP WITH THIS FORM
based on current employment. This information is needed to
process your Medicare enrollment application.
• Phone: Call Social Security at 1-800-772-1213
The employer that provides the group health plan coverage
• En español: Llame a SSA gratis al 1-800-772-1213 y oprima
completes the information about your health care coverage
el 2 si desea el servicio en español y espere a que le
and dates of employment.
atienda un agente.
• In person: Your local Social Security office. For an office
HOW IS THE FORM COMPLETED?
near you check
• Complete the first section of the form so that the
employer can find and complete the information about
your coverage and the employment of the person
through which you have that health coverage.
• The employer fills in the information in the second
section and signs at the bottom.
Form CMS-L564 (CMS-R-297) ( 0 9/1 6)
1

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