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CMS-L564 form (Revised 03/2025): fill out online, free to start

Form CMS-L564 is the Centers for Medicare & Medicaid Services's “Medicare Request for Employment Information.” In its words: “Use this form to show proof of group health plan coverage based on current employment so you can enroll in Medicare.” (CMS, Form CMS-L564 (Revised 03/2025), page 1)

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Fill it nowOfficial form on cms.gov

We don't sell your data. This tool runs in your browser, so your files stay on your device and are never uploaded. What you type, including a Social Security number, stays on your device.

Also searched as: CMS-L564, CMS L564 form, Medicare Request for Employment Information, Medicare Part B employment verification form, L564 form.

CMS-L564 at a glance

Form CMS-L564 at a glance
AgencyCenters for Medicare & Medicaid Services (CMS)
What it is forUse this form to show proof of group health plan coverage based on current employment so you can enroll in Medicare.
Who fills itIn the form’s words: “You complete Section A of this form, then ask your employer to fill out Section B.”
Who it goes to“Mail or fax this completed form together with your Application for Enrollment in Medicare (CMS-40B) to your local Social Security office.”
SignatureSection B ends with a “Signature of company official” line, with the date signed, the official’s title and a phone number. It is for the employer’s official.
RevisionRevised 03/2025
Last checked
Official form and instructionsOfficial form (PDF) · Official instructions

For what to enter on each line, read the agency's instructions.

What the agency says

  • The form says: “To enroll in Medicare through a Special Enrollment Period, you must have had group health plan coverage through your or your spouse’s current employment since the first month you were eligible for Medicare Part B. Your coverage must not have ended more than 8 months ago.”

    Source: CMS, Form CMS-L564, page 1 (checked November 1, 2026)

How to fill out the CMS-L564 with PDFinish

  1. Open the form. Press Fill it now. The form opens in Finish PDF in your browser. Nothing is uploaded.

  2. Type in the boxes. Click a box and type, or tick a checkbox. Add your signature in the Sign step and press Lock to put your entries into the page.

  3. Save your copy. Name the file and download it. Your original blank form is never changed.

Questions about the CMS-L564 form

Is there a 2026 CMS-L564?

CMS does not put a year in the form’s name. The file CMS publishes at the address below is marked “Revised 03/2025” and “Expires: 03/2028” (OMB No. 0938-0787). This page carries that file, which we compared with CMS’s copy on November 1, 2026: https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms-l564e.pdf.

Is the CMS-L564 form free to fill out here?

Free to start. Your 2 free uses in total need no account. Filling in a form and signing it are free; the file you download counts as one of your free uses. After that, start your 7-day free trial of Pro or buy Pro for $2.99 a month.

Is my information uploaded?

No. The form is filled in your browser and never uploaded, so what you type, including any Social Security number or other tax ID, stays on your device. We do not record what you type.

Is this the latest version of Form CMS-L564?

It is the version the agency listed as current when we last checked on 2026-11-01: Revised 03/2025. We compare our copy with the agency's every week. If the agency updates the form, this page says so and points to the official link until we update ours.

Who signs the CMS-L564?

On the form, Section B ends with a “Signature of company official” line, so that signature is for your employer’s official. The form says: “You complete Section A of this form, then ask your employer to fill out Section B.” Fill in Section A here, save the file, and send it to your employer.

Where do I send the CMS-L564?

In the agency's words: “Mail or fax this completed form together with your Application for Enrollment in Medicare (CMS-40B) to your local Social Security office.” Read the agency's instructions at https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms-l564e.pdf.

What do I put in each box of the CMS-L564?

We do not tell you what to enter. The agency's own instructions explain each line: https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms-l564e.pdf.

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Sources

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