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You need to get the completed form from your employer and include it with your Application for Enrollment in Medicare (CMS-40B). Then you send both together to your local Social Security office. Find your local office here: www.ssa.gov .
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Form Approved OMB No. 0938-0787. REQUEST FOR EMPLOYMENT INFORMATION. WHAT IS THE PURPOSE OF THIS FORM? In order to apply for Medicare in a Special Enrollment Period, you must have or had group health plan coverage within the last 8 months through your or your spouse’s current employment. People with disabilities must have large
The CMS-L564 is called a request for employment information. You are responsible to fill out Section A of this form with your employer’s name and address. The purpose of this form is to verify that you’ve been employed and had employer coverage from the time you turned 65 to enrollment in Medicare.
Form CMS-L564, Request for Employment Information, also known as Form CMS-R-297, is a legal document you must complete to prove the group health plan coverage based on your or your spouse's current employment.
The latest form for Request for Employment Information (CMS-R-297/CMS-L564) expires 2023-06-30 and can be found here.
31 maj 2023 · The form CMS-L564, also referred to as CMS-R-297, is used, in conjunction with form CMS40B, Application for Supplementary Medical Insurance, during an individual’s special enrollment period (SEP). Completed by an employer, the CMS-L564 provides proof of an applicant’s employer group health coverage.
View, download and print fillable Cms-l564 (cms-r-297) - Request For Employment Information in PDF format online. Browse 172 Cms Forms And Templates collected for any of your needs.
