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CMS L564. Request for employment information

CMS L564. Request for employment information

Form CMS L564/R297, approved by the Centers for Medicare & Medicaid Services (CMS), is an official Request for Employment Information. This form is primarily used to verify group health plan coverage when applying for Medicare during a Special Enrollment Period (SEP). It ensures that individuals and people with disabilities meet eligibility requirements based on current or recent employment coverage.

Purpose of the Form

The main purpose of this form is to provide documented proof of group health coverage through employment. Medicare uses this information to process applications accurately. Without this form, applicants may face delays in their enrollment or risk missing deadlines.

Who Should Complete This Form

The form involves two parties:

  • Applicant: The individual applying for Medicare Part B must complete Section A.
  • Employer: The employer or company official completes Section B, confirming coverage details and employment dates.

Typical mistakes include leaving out dates of coverage, incorrect Social Security Numbers, or failing to submit the completed form with the Medicare application.

Legal and Regulatory Context

This form is mandated by federal regulations under the Social Security Act. Compliance is required to verify eligibility during Special Enrollment Periods, particularly for individuals with disabilities or those seeking Medicare after leaving employer coverage. The form carries legal weight because false or incomplete information can affect Medicare enrollment and may trigger follow-up audits by CMS.

Section-by-Section Breakdown

Section A: Applicant Information

The applicant provides basic information to allow the employer to identify the person whose coverage must be verified. This includes:

  • Employer’s name and address
  • Applicant and employee names and Social Security Numbers
  • Date of completion

Practical tip: Double-check all Social Security numbers and names for accuracy. Incomplete Section A may result in rejection by CMS.

Section B: Employer Completion

The employer confirms coverage and employment details:

  • Indicate if the applicant was covered under a group health plan
  • Provide coverage start and end dates
  • Employment start and end dates
  • For large group plans with disabled individuals, specify primary payer periods
  • Hours Bank Arrangements, if applicable
  • Signature, date, title, and phone number of company official

Common errors: Missing signature, incorrect coverage dates, or unclear employment dates. Employers should verify data before submission.

Practical Advice for Completing the Form

  • Complete Section A clearly and legibly before sending to your employer.
  • Request your employer to complete Section B promptly.
  • Submit the completed form together with your Medicare Part B application (CMS-40B) to the local Social Security office.
  • Keep copies of all submissions for your records.

Examples of When This Form Is Required

  • A retiree enrolling in Medicare outside the standard enrollment period, having had prior group coverage through a former employer.
  • An individual with disabilities whose coverage is based on a spouse’s current employment.
  • Someone who left a job and needs to confirm recent group health coverage to avoid penalties or gaps in Medicare.

Documents Typically Attached

  • Completed Form CMS L564/R297
  • Medicare Part B application (CMS-40B)
  • Employer proof of group health plan (if requested)

Frequently Asked Questions (FAQ)

  • Q: Who fills out Form CMS L564/R297? A: Section A by the applicant, Section B by the employer.
  • Q: When should I submit this form? A: Alongside the Medicare Part B application during a Special Enrollment Period.
  • Q: What if my employer refuses to complete Section B? A: Contact Social Security for guidance and possible alternative verification.
  • Q: Can I submit the form without Section B? A: No, CMS requires employer verification for eligibility.
  • Q: Are electronic submissions accepted? A: Usually, the form must be mailed or delivered in person; check local Social Security office requirements.

Micro-FAQ (Short Answers)

  • Purpose: Verify group health coverage for Medicare enrollment.
  • Who files: Applicant and employer.
  • Deadline: Submit with Medicare Part B application.
  • Attachments: CMS L564/R297 and CMS-40B.
  • Submitted to: Local Social Security office.
  • Signature needed: Employer’s official.
  • Consequences: Delayed or denied enrollment if incomplete.

Related Forms

  • CMS-40B: Application for Medicare Part B
  • CMS L564/R297 Supplement for Disabled Individuals
  • Other state-specific Medicare verification forms
  • Group health plan proof documents

Form Details / Metadata

  • Form Name: Request for Employment Information
  • Form Number: CMS L564/R297
  • Agency: Centers for Medicare & Medicaid Services (CMS), Department of Health and Human Services
  • Region: United States
  • Revision Date: 08/20 (Expires 06/2023)
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