CMS L564/R297 2010 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 Number: Social Security Administration

How to fill out CMS L564R297

How to fill out CMS L564/R297

1. Obtain the CMS L564/R297 form from the CMS website or your healthcare provider.
2. Fill in your personal information including your name, address, and Medicare number in the designated fields.
3. Complete the sections that inquire about your health coverage and employment status.
4. Ensure the dates and other requested information are accurate and complete.
5. Sign and date the form at the bottom to certify that all the provided information is true.
6. Submit the completed form to the appropriate Medicare plan or service center as instructed.

Who needs CMS L564/R297?

1. Individuals who are seeking to enroll in a Medicare plan and need to verify their health coverage from previous jobs.
2. People who qualify for Special Enrollment Periods due to changes in their employment or health coverage.

Social Security Claim Request for Employment Information & Making a Template

If you’re a boss, business owner, or employer, one of your employees may end up applying for Medicare or Medicaid services. When they do, the Social Security Claim Request for Employment Information form into a template for later use.

How to turn the Social Security Claim Request form into a template:

1. In the “My Forms” page, select the Social Security Claim Request for Employment Information form.
2. Type in the information & add the signatures that you always want the template to contain (information that always stays the same), like your company’s name, address, phone number, your supervisor title, and signature.
3. Click the red “DONE” button to save. You’ll be automatically taken back to the “My Forms” page.
4. Now, select the document you just edited, and click the “Template” button. If you can’t find the button right away, click “More” and a list with drop down with more clickable functions (see the image below for an example).5. Your claim form has now been instantly converted into a template.  You’ll know which one it is because it’ll be labeled with a “T.”

From now on, every time you open this template document, it will include the permanent information you saved, but you will be able to enter all the unique employee/claimant information for each individual work situation. CMS-L564 form template (or any of your other templates) changes, you can make edits anytime. To learn more about making your PDFfiller account really work for your business, click here.

When you’re finished answering the form’s employment questions, you have a few options. Save a stamp and eFax the form directly to the Social Security Department, email it, or simply print it out and tuck it into the return envelope they’ve already supplied for you.

We hope this tutorial makes life and work easier for you and your employees. If you have any comments or questions, we’d love to hear from you.

Thanks for stopping by!

People Also Ask about

Who completes CMS-L564 form?

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 is a CMS L564 Request for employment information?

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 send my CMS L564 form?

If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, MD 21244-1850.

Where do I send my Medicare cancellation form?

By regular mail. You may mail written comments to the following address: CMS, Office of Strategic Operations and Regulatory Affairs, Division of Regulations Development, Attention: Document Identifier/OMB Control Number , Room C4-26-05, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.

What is a L564?

Form CMS-L564 is an employment information form from the Social Security Administration (SSA). It's used in conjunction with Form CMS-40B when you apply for Medicare part B during a special enrollment period (SEP). One portion is completed by you and the other is completed by your employer or your spouse's employer.

Can I submit form CMS L564 online?

You can complete the Part B SEP online or you can mail your completed CMS 40B, Application for Enrollment in Medicare - Part B (Medical Insurance) and CMS L564 - Request for Employment Information to your local Social Security office.

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What is CMS L564/R297?

CMS L564/R297 is a form used for reporting health coverage information to the Centers for Medicare & Medicaid Services (CMS), particularly for individuals who are applying for Medicare.

Who is required to file CMS L564/R297?

Individuals who are applying for Medicare and have had health coverage outside of Medicare, especially those eligible for Special Enrollment Periods (SEPs), are required to file CMS L564/R297.

How to fill out CMS L564/R297?

To fill out CMS L564/R297, individuals need to provide personal information, details of their prior health coverage, and the duration of that coverage. They should follow the instructions provided on the form carefully.

What is the purpose of CMS L564/R297?

The purpose of CMS L564/R297 is to verify an individual's prior health coverage status, which can determine eligibility for Medicare enrollment and potential Special Enrollment Periods.

What information must be reported on CMS L564/R297?

CMS L564/R297 requires information such as the applicant's name, date of birth, Social Security number, the type of prior health coverage, the start and end dates of that coverage, and the employer's information if applicable.