Medicare Form CMS-L564 is used to prove you had employer group health coverage if you delayed Medicare Part B while still working. The form proved you had creditable coverage so you can qualify for a Medicare Special Enrollment Period (SEP) and avoid late enrollment penalties. Your employer completes Section B of the form, and you complete Section A. The completed form gets submitted with your Part B application.
Medicare Form CMS-L564 Quick Facts
| Topic Point | Details |
|---|---|
| Form Name | CMS-L564 Request for Employment Information |
| Used For | Proof of employer health coverage |
| Helps Avoid | Medicare Part B late penalties |
| Needed When | Delaying Part B after working past age 65 |
| Completed By | Employee and employer |
| Submitted With | Medicare CMS-40B Part B application |
| Common Mistake | Incorrect coverage dates |
We often see confusion around filling out this form — especially about who signs and employment coverage dates. Follow this guide to ensure you complete the form accurately and prevent any delays or penalties.
Who needs Medicare form CMS-L564?
You need form CMS-L564 if you delayed taking Part B when first eligible because you or your spouse was still working and covered by creditable group health insurance. When you leave your employer plan, you will need form CMS-L564 to provide proof that you had creditable coverage during the time that you delayed Part B. This proof triggers a special enrollment period to enroll in Part B outside of your Initial Enrollment Period.
If you are enrolling in Medicare during your IEP, then you do not need to complete this form. Your IEP is the 7-month period around your 65th birthday month. It includes the 3 months before your birthday month, the month of your birthday, and extends 3 months after your birthday. If only you delayed Medicare a couple of months due employer coverage, but are still within this 7-month period, then you DO NOT need to complete this form.
How Do You Complete Medicare Form CMS-L564?
All sections of the form need to be completed with the employee information, applicants information (if different), employer information, the dates of employment, dates of creditable group coverage, as well as the name, title, and signature of employer official verifying the information.
You can download a PDF copy of the CMS-L564 Request for Employment Information from the CMS website. Below is a detailed breakdown of each section and how to ensure your employer provides accurate information.
Who Fills Out Section A?
The employee will complete Section A of the form with the Employer’s name and address, and the applicant’s information. The applicant’s information may be different than the employee if it is a non-employee spouse covered by the group plan.
Who Fills Out Section B?
The Employer completes Section B, which covers the rest of the form and verifies dates of employment and dates of creditable coverage. Most of the employer section is self-explanatory, but there are a few areas to double check for accuracy:
- Section B question 5, the employer needs to indicate when the employee worked for the company. We see numerous areas of confusion in this question. It is critical that the employer lists the start and end date, or “still employed” dates of employment for the employee. Some employers incorrectly fill out the current benefit year as the start of employment date. They need to put the actual hire date in this section. If the employee still works for the company when completing the form, they must list the month and year of the application date.
- Signature of Company Official, title, and date. This section often gets overlooked because it appears at the bottom of the form. Human Resources or the employer must complete and sign it, or the form will remain incomplete.
Make sure the form is filled out correctly before sending it to Medicare! Any missing information can cause delays when processing your Medicare application. It could also implement incorrect Part B penalties if your previous coverage dates are wrong. If you are unsure that your Request for Employment Information is filled out correctly, you can reach out to one of our licensed agents. We have helped many retirees verify this form is correct!
You need to submit this form with your Medicare Enrollment Form.
Eric is a licensed agent specializing in helping Medicare beneficiaries navigate Medicare. He educates and assists beneficiaries with Medicare enrollment, coverage options, timelines, costs, and more.
My husbands former employer lied and checked the no box saying he had no insurance coverage. How do we fight that?
Hi Michelle,
Is it possible they just accidentally filled it out wrong? I would first check with them to see if you can get them to correct it. If they refuse, then you can use alternative documentation. Send in a letter stating the employer filled it out wrong, along with another form of proof of insurance. You may be able to get something from logging into your insurance portal to show you had coverage, or each tax year you would have received a tax documentation showing months of coverage throughout the year.