Get the free CMS - L564. Request for Employment Information

Form Approved OMB No. 09380787 Expires: 06/2023DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICESREQUEST FOR EMPLOYMENT INFORMATION WHAT IS THE PURPOSE OF THIS FORM?WHAT

How to fill out cms - l564 request

How to fill out cms - l564 request

1. To fill out a CMS-L564 request, follow these steps:
2. Obtain the CMS-L564 form from your local Social Security office or download it from the official Social Security Administration website.
3. Read the instructions provided with the form carefully to understand the requirements and eligibility criteria.
4. Gather all the necessary documents and information, such as your Social Security number, proof of age, and proof of employment.
5. Start by filling out your personal information section, which includes your name, address, contact details, and Social Security number.
6. Provide information about the employer or union that maintains your employer group health plan.
7. Indicate the type of coverage you have, whether it's Medicare Part B, an employer-sponsored group health plan, or both.
8. Attach any supporting documentation, such as copies of your Medicare card or other insurance cards.
9. Sign and date the form, certifying that the information provided is true and accurate to the best of your knowledge.
10. Submit the completed CMS-L564 request form to your local Social Security office or mail it to the address specified in the instructions.
11. Keep a copy of the filled-out form and any submitted documents for your records.

Who needs cms - l564 request?

1. Anyone who is eligible for Medicare Part B and has employer-sponsored group health coverage may need to submit a CMS-L564 request.
2. This form is required to establish the entitlement to Medicare Part B without penalties.
3. Individuals who are still actively working and covered under an employer or union group health plan can use this form to apply for Medicare Part B and avoid late enrollment penalties.
4. Retirees who have delayed Medicare Part B enrollment due to their employer's group health coverage may also need to submit this form to initiate their Part B coverage.
5. Additionally, individuals who have lost their employer group health coverage or are transitioning from a retiree health plan to Medicare Part B may need to complete and submit the CMS-L564 request form.

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What is cms - l564 request?

CMS-L564 is a form used to verify other health insurance coverage for Medicare beneficiaries.

Who is required to file cms - l564 request?

Medicare beneficiaries who have other health insurance coverage are required to file CMS-L564 request.

How to fill out cms - l564 request?

To fill out CMS-L564 request, the beneficiary must provide information about their other health insurance coverage such as name of insurance company, policy number, and effective dates.

What is the purpose of cms - l564 request?

The purpose of CMS-L564 request is to verify other health insurance coverage so that Medicare can coordinate benefits and avoid duplicate payments.

What information must be reported on cms - l564 request?

The information reported on CMS-L564 request includes details of other health insurance coverage such as name of insurance company, policy number, and effective dates.