CMS-L564 Form: How to Complete Medicare's Request for Employment Information

If you worked past 65 with employer health insurance, CMS-L564 is the single most important form standing between you and penalty-free Medicare Part B enrollment. Get it wrong — or skip it — and you could face a permanent 10% premium surcharge for every year you delayed.

The CMS-L564, officially titled "Request for Employment Information," proves to Medicare that your delay in enrolling was covered by active group health insurance. Without it, the Social Security Administration treats your gap as unexcused, and the late enrollment penalty kicks in for life.

What the CMS-L564 Form Does

CMS-L564 serves one purpose: it certifies that you had group health plan coverage based on current, active employment. This is the documentation Medicare requires to grant you a Special Enrollment Period (SEP) — the 8-month penalty-free window that starts when your employment or group coverage ends, whichever comes first.

The form has two sections:

• Section A — You fill this out. It captures your name, Medicare number, employer name, and the dates your group coverage was active.
• Section B — Your employer fills this out. An authorized company representative certifies that you were continuously covered under the group plan based on active employment. Electronic signatures, rubber stamps, and stylus signatures are all acceptable — a wet ink signature is not required.

How CMS-40B Works with CMS-L564

You always submit CMS-L564 alongside CMS-40B (Application for Enrollment in Medicare Part B). Think of them as a matched pair:

• CMS-40B is your actual Part B enrollment application
• CMS-L564 is the proof that your delay was legitimate

Submit both together to your local Social Security field office by fax, mail, or in-person appointment. Without the L564, your 40B application gets processed as a General Enrollment Period request — meaning delayed coverage and a lifetime penalty.

Step-by-Step: Filling Out CMS-L564 and CMS-40B

60 days before your last day of work:

1. Download both forms from CMS.gov
2. Complete Section A of CMS-L564 with your personal information, employer name, and employment dates
3. Complete CMS-40B with your Medicare claim number and requested Part B start date
4. Send CMS-L564 to your HR department or benefits administrator

45 days before retirement:

5. Follow up with HR to ensure Section B of CMS-L564 is completed and signed by an authorized representative
6. Get the signed form back — don't let it sit in an inbox

30 days before retirement:

7. Submit both completed forms together to your local SSA field office
8. Request that Part B coverage begin on the first day of your retirement month to avoid any gap

The 8-Month Deadline You Cannot Miss

Your Special Enrollment Period runs for exactly 8 months from the date your active employment or group health coverage ends — whichever happens first. Miss that window, and you'll wait until the next General Enrollment Period (January 1 through March 31), with coverage not starting until the following month.

The penalty math is straightforward: the standard Part B premium in 2026 is $202.90 per month. For every full 12-month period you were eligible but didn't enroll, you pay a 10% surcharge on that premium — permanently. A 2-year delay adds $40.58 per month to your premium for the rest of your life.

Common CMS-L564 Mistakes

Employer drags their feet on Section B. Start the process 60 days out, not 30. HR departments move slowly, and you're the only one who suffers if the form is late.

Confusing COBRA with active employer coverage. COBRA does not count as group coverage based on current employment. If you retired and elected COBRA, your 8-month SEP clock started when your active employment ended — not when COBRA runs out.

Submitting CMS-40B without CMS-L564. The enrollment application alone doesn't prove your delay was covered. Without the employment verification, SSA may process your enrollment with penalties attached.

Waiting until after retirement to start. You can submit these forms up to 60 days before your last day of active employment. Earlier submission means seamless coverage with no gap.

When to Use CMS-4040 Instead

If you don't qualify for premium-free Part A (fewer than 40 work credits) and you're not receiving Social Security retirement benefits, CMS-40B won't work for you. In that case, use Form CMS-4040 (Request for Enrollment in Supplementary Medical Insurance) to apply for Part B.

Get the Complete Enrollment Toolkit

The Medicare Enrollment Guide walks through all three enrollment pathways — initial, special, and general — with pre-annotated form instructions, an employer coordination timeline, and penalty calculators. It covers the exact sequence for CMS-L564, CMS-40B, and every other form you'll need for a gap-free transition.

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