About this 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.

How do I fill out Form CMS-L564?

If you want to apply for Medicare during a special enrollment period, you must prove that you have or had group health coverage within the last 8 months. You are only responsible for filling out the first section of the form, and your employer is responsible for filling out the second part as well as sign at the bottom.

Starting with line 1, fill in your current or past employer’s name. To the right on line 2, enter today’s date. Moving down to line 3, enter the address of the employer, moving down enter the city, and to the right enter the abbreviation for the state as well as the 5-digit zip code.

Moving down to line 4, enter the applicant’s name. This is the person who is applying for Medicare enrollment. To the right on line 5, enter the applicant’s social security number. Down to line 6, enter the employee’s full name. The applicant and employee may be the same person, but fill in both lines 6 and 7. To the right on line 7, enter the employee’s social security number.

The applicant has now completed their portion of Form CMS-L564 and must have the employer complete Section B.