CMS L564 Form: How to Request It From Your Employer
October 14, 2026
The CMS-L564 form, officially titled "Request for Employment Information," is the document the Social Security Administration (SSA) uses to confirm that you or your spouse had group health coverage through an employer while you delayed enrolling in Medicare Part B. You need it to use a Special Enrollment Period (SEP), the window that lets you sign up for Part B after age 65 without paying the Part B late enrollment penalty, as long as your coverage came from your own or your spouse's current employer.
The form has two sections: one you complete yourself, and one your employer completes to verify the coverage dates. Below is exactly who fills out what, how to get it signed, and what to do if your employer won't cooperate.
Quick Answer
CMS-L564 is a two-part form: Section A is filled out by you, Section B is filled out by your employer, confirming when your group health coverage started and ended. You submit the completed form to the Social Security Administration (SSA), usually alongside the CMS-40B Part B application, to qualify for a Special Enrollment Period and avoid the Part B late enrollment penalty. If your employer can't or won't complete Section B, SSA can accept other proof, such as W-2s, pay stubs, or health plan documents showing your coverage dates.
Section A vs. Section B: Who Fills Out What
Section A asks for your basic information: name, Social Security number, Medicare number if you have one, and the reason you're requesting the form. You complete this part yourself before sending it to your employer or former employer's benefits or HR department.
Section B is completed by your employer (or your spouse's employer, if you were covered under their plan). It asks the employer to confirm:
- The dates your group health coverage began and ended
- Whether the coverage counts as medicare creditable coverage based on current employment
- Whether the plan was based on your own employment or a family member's
- The employer's contact information and an authorized signature
SSA generally requires the employer's section to be signed within 90 days of your application, so timing the request matters once you know you'll be applying.
How to Get Your CMS-L564 Completed
- Download the CMS-L564 form from SSA.gov or get it from your local Social Security office
- Fill out Section A with your name, Social Security number, and reason for the request
- Send the form to your (or your spouse's) employer's HR or benefits department for Section B
- Ask the employer to sign and date Section B, confirming your coverage start and end dates
- Submit the completed form to SSA, typically along with the CMS-40B Part B application
- Keep a copy of the signed form for your own records
If Your Employer Won't Complete the Form
Some employers, especially small companies that have closed or HR departments that don't respond, won't fill out Section B. SSA has a documented alternative process for this situation: you can submit other proof of your group health coverage instead of the employer's signature. Acceptable substitutes include W-2 forms showing health plan deductions, pay stubs with health insurance withholding, health insurance cards, or a letter from a plan administrator confirming coverage dates.
Bring or mail this evidence to your local Social Security office along with an explanation of why the employer section couldn't be completed. SSA reviews these cases individually, so it's worth calling ahead or visiting in person rather than guessing which documents will be accepted.
Where This Fits in Your Enrollment Timeline
The CMS-L564 only matters if you're using a Special Enrollment Period rather than your medicare initial enrollment period 7 month window explained. If you're retiring or losing employer coverage, understanding how medicare when you retire rules interact with your group plan can help you figure out exactly which enrollment period applies. For a broader view of how SEPs compare to open enrollment windows, see our guide to medicare enrollment periods.
Know Your Deadline
Once your employer coverage or your employment ends (whichever happens first), you generally have an 8-month Special Enrollment Period to sign up for Part B without a late enrollment penalty. According to Medicare.gov, missing this window can mean waiting for the next medicare general enrollment period deadline and facing a premium penalty that can last for years. Submit your CMS-L564 well before this window closes.
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Frequently Asked Questions
Yes. The Social Security Administration (SSA) allows you to submit the CMS-L564 along with your CMS-40B Part B application through your personal my Social Security account, by mail, or in person at a local SSA office.
No. COBRA and retiree health coverage do not count as coverage based on current employment, so they don't qualify you for a Special Enrollment Period. The form is for active employer group health coverage only, from your own or your spouse's current job.
Federal, state, and some other employer types may have their own version of the employment verification form or process. Check with your HR or benefits office, since some agencies use a modified form or an internal certification process instead of the standard CMS-L564.
Processing times vary by local office and submission method. SSA does not publish a fixed turnaround for CMS-L564 reviews, so it's worth confirming receipt and following up if you don't hear back within a few weeks, especially if your Special Enrollment Period deadline is approaching.