Complete Form CMS-L564 in Minutes with AI
Upload your CMS-L564 PDF and let AI guide you through every section, from employer details to coverage dates and signatures. Whether you need proof of group health coverage or employment history for Medicare, stop guessing and complete your form correctly the first time.
AI converts your CMS-L564 into a smart, interactive form. No squinting at small boxes or worrying about missing employer information.
Upload employment records and insurance documents as source files, and AI pulls relevant details directly into the form.
Completing the form with your employer or former employer? Auto-fill every section accurately and reduce the risk of delays in Medicare enrollment.
Form INFORMATIONS
Applicant and Employee Information:
Applicant's full legal name (must match Social Security and Medicare records) and SSN. If the applicant was covered through a spouse's employer, enter the employee's name and SSN (the person whose job provided the group health plan). This links the form to the applicant's Medicare enrollment request.
Employer Information:
Employer's official name (company or organization that provided the group health insurance), full address (street, city, state, ZIP), and EIN if required. Social Security uses this to confirm the employer's identity and contact them if additional verification is needed.
Employer Group Health Plan Coverage:
Yes or no indicating whether the applicant was covered under an employer-sponsored group health plan. This is the core eligibility check for a Special Enrollment Period without penalties. Coverage start date (month/year) and end date (if applicable); if coverage is ongoing, end date may be blank.
Employment Dates:
Employment start date (month/year the employee began working for the employer) and employment end date (if applicable). Confirms that health coverage was tied to active employment rather than COBRA or retiree coverage, which don't qualify. Helps Social Security determine when the applicant became eligible to enroll in Medicare Part B without late penalties.
Employer Certification and Signature:
Name, title, and contact details of the employer representative completing the form. This person certifies that the employment and health coverage information is accurate and complete. The employer's official signature and date confirm verification; Social Security uses this to process the Medicare Part B enrollment request. The applicant completes the first section; the employer completes and certifies the second section before submitting with the Medicare Part B application.
WHAT IS FORM CMS L564?
What Is Form CMS L564 and Who Needs to Fill It Out?
Form CMS L564, officially called "Request for Employment Information," is used to verify that you had group health plan coverage through an employer based on current employment. It tells Social Security that the reason you didn't enroll in Medicare Part B when you first became eligible was because you already had health insurance through your job or your spouse's job—not that you forgot or chose not to. The form doesn't enroll you in Medicare; it proves your coverage history so Social Security can grant you a Special Enrollment Period and waive the late enrollment penalty.
Unlike a letter from your employer or a benefits summary, Form CMS L564 is the specific document Social Security requires. No other documentation substitutes for it. You need it if: you turned 65 and didn't enroll in Part B because you were covered under an employer's group health plan; you're retiring or losing employer coverage and need to enroll within the 8-month Special Enrollment Period; your spouse's employer provided your coverage and that coverage is ending; your employer dropped or changed the plan; or you already missed your Initial Enrollment Period and need to avoid the 10% late enrollment penalty (which lasts for life).
You complete the top section with your personal details; your employer completes the bottom with coverage dates, employment dates, and certification. Coverage date accuracy, the distinction between active employment and COBRA/retiree coverage (which don't count), and the 8-month filing window often trip people up. Simplicity AI guides you through each section and helps ensure dates and details are correct.
How to Fill Out Your CMS-L564 Online in 6 Simple Steps
1
Upload your blank Form CMS-L564 PDF to the AI tool. The AI scans the form layout and converts it into a guided interactive questionnaire.
2
Enter the employee's personal information and Social Security number. This identifies the individual requesting Medicare-related employment verification.
3
Enter the employer's name, address, and EIN. If you upload employment records, the AI automatically extracts employer details.
4
Enter employment dates and group health plan coverage dates. Upload insurance statements or HR records so AI can pull accurate timelines.
5
Review all information carefully to ensure employment dates and coverage periods match employer records. Even small discrepancies can delay Medicare processing.
6
Export your completed CMS-L564 as a clean PDF. Have the employer representative sign it, then submit it with your Medicare application.
Super Fast
Complete your CMS-L564 in minutes instead of hours. AI extracts employment and coverage details from uploaded documents and auto-fills the form.
AI-Powered
The AI understands the CMS-L564 structure, from employee identification to employer verification and coverage timelines, and maps your answers to the correct fields.
Secure
Your CMS-L564 contains Social Security numbers, employer data, and insurance information. Documents are encrypted, handled privately, and never shared. Your data remains under your control.
FAQs
FORM CMS-L564: Frequently Asked Questions
What is Form CMS-L564, and why do I need to file it?
Form CMS-L564 is used to verify employment and group health plan coverage for Medicare purposes. It helps Social Security determine whether you qualify for a Special Enrollment Period and whether late enrollment penalties should apply.
How do I fill out CMS-L564 online for free?
Upload your CMS-L564 PDF to the AI platform. The system converts it into an interactive form that guides you through each section, including employee information, employer details, and coverage dates. Review your entries and export a ready-to-submit PDF.
Who completes Form CMS-L564?
The employer or former employer completes and signs the form. The employee provides personal information, but Social Security requires the employer to certify employment and coverage details.
What documents do I need to complete CMS-L564?
Employers typically use HR records, payroll data, and group health plan documents to complete the form. Employees may need to provide insurance statements or employment records to help their employer fill out the form accurately.
How long does it take Social Security to process CMS-L564?
Processing times vary depending on the completeness of the form and supporting documents. Delays often occur when employment dates or coverage information are missing or inconsistent.
Can CMS-L564 help me avoid Medicare penalties?
Yes. If CMS-L564 proves that you had continuous employer-sponsored coverage, Social Security may waive late enrollment penalties when you enroll in Medicare Part B.
Common Mistakes When Filing Form CMS-L564
(and How AI Prevents Them)
Incorrect Employment Dates
Providing wrong start or end dates is one of the most common errors. AI extracts employment timelines from uploaded records to ensure accuracy.
Missing Group Health Plan Coverage Dates
Failing to include coverage start and end dates can cause Social Security to reject the form. AI prompts you to enter and verify these dates before finalizing the form.
Employer Information Errors
Misspelled employer names or incorrect EINs can delay verification. AI pulls employer data from uploaded documents to reduce manual errors.
Unsigned Employer Section
If the employer representative does not sign the form, it will not be processed. AI highlights signature fields to ensure they are completed.
Inconsistent Information Between Records
Differences between HR records and the form can raise questions during review. AI cross-checks uploaded documents with entered data to reduce inconsistencies.
Submitting Incomplete Forms
Leaving sections blank can delay Medicare processing. AI flags missing fields and ensures the CMS-L564 is complete before submission.
POPULAR FORMS
Popular forms ready for you to fill Instantly
Find commonly used government, legal, and official documents, already optimized for fast, stress-free filling with Simplicity AI. We’ve made them easier, smarter, and faster so you can move on with your day.
Tax Forms
Immigration Forms
Healthcare Forms
Employment Forms
Legal Forms
Motor Vehicle Forms
Experience instant PDF form filling with AI
