Form CMS-L564: how to fill it out, with a filled example
CMS-L564Ed. 03/2025
Form CMS-L564, "Request for Employment Information," is your employer's proof that you had health coverage from a current job after 65. Send it with Form CMS-40B to sign up for Part B late without a penalty.
What this form does
Your deadline: 8 months
Do you need the CMS-L564?
You need it if all of these are true:
- You are 65 or older and didn't sign up for Part B when you first could.
- Since turning 65 you had health coverage from an employer or union group health plan.
- That coverage came from someone's current job: yours or your spouse's.
- The job or the coverage has ended, or is about to.
You don't need it if you are signing up in your first window around your 65th birthday, or in the General Enrollment Period (January to March) after missing your 8 months.
Section A: what you fill in
Fill in Section A before you hand the form to HR, so they know exactly who it is for. Here is a filled example for Walt, who retired in July 2026.
Section B: what your employer fills in
This is the part Social Security cares about. Here is what a correct Section B looks like.
Example fields are simplified from Form CMS-L564 (03/2025). Use the official form.
The 5 mistakes HR makes most, and what to say
| Mistake | What to ask for |
|---|---|
| Coverage end date left blank | "Please add the month my group coverage ended, in mm/yyyy." |
| COBRA dates written instead of active coverage | "Please give the dates I was covered as an active employee. COBRA doesn't count for this form." |
| Only the year written ("2026") | "Please write the month and year for each date." |
| Signed, but no title or phone number | "Please add your title and a phone number, in case Social Security needs to confirm." |
| Filled in by a payroll company with no plan details | "Please have the person who manages the health plan complete it, or ask the insurer for a letter with my coverage dates." |
If your employer won't sign, or is gone
Your employer is slow, closed, sold, or won't fill in Section B. You can still sign up on time. First, ask the insurer (the number on your card), the payroll or benefits company, or the new owner after a sale for a letter that states your coverage dates.
If no one can complete Section B, fill in Section A, leave Section B blank, and send at least one of these instead:
| Document | What makes it useful |
|---|---|
| Pay stubs showing health insurance deductions | Best for showing coverage right up to the end. Send your last one, plus one from around the month you turned 65. |
| W-2s showing pre-tax medical contributions | One for each year since you turned 65. Box 12, code DD shows the cost of employer health coverage. |
| Health insurance card with a policy effective date | Only counts if the card shows a start date. Copy both sides. |
| Explanations of benefits paid by the group plan | Show the plan was paying your claims. Pick recent ones, close to the end date. |
| Tax returns showing health insurance premiums paid | Useful if your premiums show on your return. |
| Statements or receipts for premium payments | For example, a letter from the plan confirming premiums were paid. |
Together, your documents should cover the months from when you turned 65 to when the coverage ended. Write your name and Medicare number on every page, and add a short signed note explaining why Section B is blank. Don't wait for HR past your deadline: send what you have.
How to send the CMS-L564
- Online (our pick)Apply for Part B on Social Security's Part B only page. You answer the CMS-40B questions on screen and upload the signed CMS-L564 or your other proof.
- By fax or mailSend it with your signed CMS-40B to your local Social Security office. Find it with the office locator. There is no national address for these forms.
- Keep proofSave the online confirmation, the fax confirmation sheet or the certified-mail receipt. It proves you applied inside your 8 months.
One full year late adds $20.29 a month to your Part B bill in 2026, for life. The kit costs $39 once.
Filled-in examples of Forms CMS-40B and CMS-L564, plus a plan for when your old employer is slow, gone, or won't sign.
- Filled CMS-40B example
- Filled CMS-L564 example for your employer
- If your employer won't sign or is gone
- 8-month deadline worksheet
- Plus 3 free bonuses, including the Letter to Your Employer's HR
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The official forms are free from ssa.gov and cms.gov. The kit is the help filling them in and proving your case. See everything inside
Questions people ask
Where do I get Form CMS-L564?
It's free on cms.gov. Search for "CMS-L564". Social Security also links to it from its page on signing up for Part B only.
Do I need a CMS-L564 if I'm signing up at 65?
No. The CMS-L564 is only for people who sign up for Part B late, in a Special Enrollment Period, because they had health coverage from a current job. At 65 you use your Initial Enrollment Period and need no proof of coverage.
Who signs the CMS-L564?
You fill in and sign nothing in Section B. Your employer (usually HR or the benefits manager) completes and signs Section B. If the coverage came from your spouse's job, it's your spouse's employer.
My employer went out of business. What now?
Fill in Section A, leave Section B blank, and send other proof of your coverage: pay stubs with health deductions, W-2s, an insurance card with an effective date, or a letter from the insurer. Add a short signed note explaining why Section B is blank.
I had COBRA after I left. Do I list COBRA months?
No. Section B is about coverage while you or your spouse were actively working. COBRA doesn't count and doesn't extend your 8-month deadline.
Do I need one form for each employer?
You need proof that covers the months since you turned 65. If you had coverage through more than one employer in that time, send a CMS-L564 (or other proof) for each.