CMS L564/R297 2000 free printable template

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES FORM APPROVED OMB NO. 0938-0787 REQUEST FOR EMPLOYMENT INFORMATION From Telephone No. Social Security Administration Employer s Name and Address Date Employee s Social Security Number Claimant s Name Claim Number Dear Sir/Madam We need the following information regarding the above claimant. You may call at the above telephone number if you have any questions. Sincerely Office Manager 1. Is or was the claimant...

How to fill out CMS L564R297

How to fill out CMS L564/R297

1. Obtain CMS L564/R297 form from the official CMS website.
2. Fill in the required personal information, including name, address, and Social Security number.
3. Provide details about your employment history, including dates of employment and employer information.
4. Indicate any coverage periods under Medicare or other health insurance plans.
5. Sign and date the form to certify that the information provided is accurate.
6. Submit the completed form to the appropriate Medicare office or your health insurance provider.

Who needs CMS L564/R297?

1. Individuals who are applying for Medicare and are seeking a Special Enrollment Period.
2. People who have gained or lost health coverage and need to qualify for Medicare.
3. Employees who are transitioning from employer-sponsored health coverage to Medicare.

Instructions and Help about CMS L564R297

People Also Ask about

How do I enroll in Medicare Part B for the first time?

Medicare will enroll you in Part B automatically. Your Medicare card will be mailed to you about 3 months before your 65th birthday. If you're not getting disability benefits and Medicare when you turn 65, you'll need to call or visit your local Social Security office, or call Social Security at 1-800-772-1213.

Are you automatically signed up for Medicare Part B?

You get Part A automatically. If you want Part B, you need to sign up for it. If you don't sign up for Part B within 3 months of turning 65, you might have to wait to sign up and pay a monthly late enrollment penalty.

What is a CMS l564 form for?

This form is used for proof of group health care coverage based on current employment. This information is needed to process your Medicare enrollment application. The employer that provides the group health plan coverage completes the information about your health care coverage and dates of employment.

Where do I fax CMS-L564?

You can complete form CMS-40B (Application for Enrollment in Medicare – Part B [Medical Insurance]) and CMS-L564 (Request for Employment Information) online. You can also fax the CMS-40B and CMS-L564 to 1-833-914-2016; or return forms by mail to your local Social Security office.

What is a CMS-L564 form for?

This form is used for proof of group health care coverage based on current employment. This information is needed to process your Medicare enrollment application. The employer that provides the group health plan coverage completes the information about your health care coverage and dates of employment.

What forms are needed for Medicare Part B?

Fill out Form CMS-40B (Application for Enrollment in Medicare Part B). Send the completed form to your local Social Security office by fax or mail. Call 1-800-772-1213. TTY users can call 1-800-325-0778.

How long is a CMS-L564 good for?

If the employment and/or the coverage has ended, the SEP extends for eight months after the month that the benefits ended. Form CMS-L564 is how you verify that you meet these conditions.

For pdfFiller’s FAQs

What is form cms l564?

Form CMS-L564, also known as the Request for Employment Information, is a document used by the Centers for Medicare & Medicaid Services (CMS) to verify an individual's current or previous employment status for the purpose of determining eligibility for Medicare Part B premium-free coverage. This form is typically completed by an individual who is retiring or leaving employment and wishes to enroll in Medicare Part B. It requires information from the employer, such as the dates of employment and employer contact details, to confirm the individual's work history and eligibility for premium-free Medicare Part B coverage.

Who is required to file form cms l564?

Individuals who are entitled to Medicare Part B but do not wish to enroll in it because they have employer-sponsored group health plan coverage, or coverage through a spouse's employer-sponsored group health plan, are required to file Form CMS-L564. This form is used to request a Special Enrollment Period (SEP) for Part B without penalty when their current coverage ends.

How to fill out form cms l564?

To fill out Form CMS-L564 (Request for Employment Information) correctly, follow these steps: 1. Download the form: Go to the official website of the Centers for Medicare & Medicaid Services (CMS) and search for Form CMS-L564. Download and print the form. 2. Section 1: Provide your personal information in Section 1, including your name, Medicare claim number, address, city, state, ZIP code, and phone number. Include your signature and the date. 3. Section 2: This section is to be completed by your employer or former employer. Provide the name and address of the company, along with the employment dates and the position you held. Make sure the employer fills out the form accurately and includes their contact information, signature, and date. 4. Section 3: If you are still employed, you may need to attach proof of current employment, such as a pay stub or a letter from your employer. 5. Section 4: This section requires the signature of a representative of your employer who can certify the information provided in Section 2. 6. Submitting the form: Once you have completed the form, make a copy for your records. Send the original completed form to the Social Security Administration (SSA) office handling your Medicare enrollment. Keep in mind that you may also need to provide other documents along with this form when submitting your Medicare application. Note: It is recommended that you consult the official instructions provided with Form CMS-L564 for detailed information and any specific requirements.

What is the purpose of form cms l564?

The purpose of Form CMS-L564 is to apply for the Special Enrollment Period (SEP) for people who have delayed enrollment in Medicare Part B because they or their spouse were actively working and had group health coverage through that employment. It is used to provide proof of the employer's group health plan coverage and is required by the Social Security Administration to verify eligibility for the SEP. This form allows individuals to avoid late enrollment penalties and sign up for Medicare Part B outside of the normal enrollment periods.

What information must be reported on form cms l564?

Form CMS L564, also known as the Request for Employment Information, is used by individuals who are eligible for Medicare because of their age but have not applied for Social Security benefits. This form is submitted to the Social Security Administration (SSA) to provide employment information to determine eligibility for Medicare without premium Part A coverage. The information reported on Form CMS L564 includes: 1. Personal Information: Full name, Social Security Number, date of birth, address, and contact information. 2. Employment Information: Details regarding the current employment status, including the name of the current employer, job title, hours worked per week, and the start and end dates of employment. 3. Group Health Plan Information: Information about any health insurance coverage provided through the employer, including the name of the plan, policy number, coverage type (individual or family), and whether the coverage is still active. 4. Signature and Date: The form must be signed and dated by the individual applying for Medicare based on age. It is important to note that submitting Form CMS L564 alone is not sufficient for Medicare enrollment. It should be submitted along with the Medicare Enrollment Application (CMS-40B), which is used to apply for Medicare Part B.

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What is CMS L564/R297?

CMS L564/R297 is a form used by individuals to verify their eligibility for premium-free Medicare Part A under certain conditions, particularly for individuals transitioning from employer-based coverage.

Who is required to file CMS L564/R297?

Individuals who are eligible for Medicare based on their age or disability and are transitioning from an employer-sponsored health plan are required to file CMS L564/R297 to confirm their eligibility.

How to fill out CMS L564/R297?

To fill out CMS L564/R297, individuals need to provide personal information such as their name, address, Social Security number, and details about their prior health coverage, including dates of coverage and the type of coverage.

What is the purpose of CMS L564/R297?

The purpose of CMS L564/R297 is to facilitate the verification of an individual's eligibility for premium-free Medicare Part A coverage for those who have recently lost employer health insurance.

What information must be reported on CMS L564/R297?

CMS L564/R297 must report information including the individual's name, Medicare number, dates of employment, details of the employer's healthcare plan, and the dates the individual was covered by that plan.