Medicare Form L564 is the document that protects you from a lifelong Part B penalty — and it’s simpler to complete than most people realize.
It sounds like a simple question, but it isn’t.
If you’re working past 65, or you recently retired from a job that covered you under a group health plan, this form is your proof.
Without it, the Social Security Administration has no way to know you had qualifying coverage — and no reason to waive the penalty you’d otherwise owe for every year you delayed enrolling in Medicare Part B.
The good news: you’re not in this alone, and this guide walks you through every step.
What Is Medicare Form L564?
Medicare Form L564 is your key to enrolling in Medicare Part B during a Special Enrollment Period without paying a penalty.
Officially titled the “Request for Employment Information,” form L564 medicare is a two-section document issued by the Centers for Medicare & Medicaid Services (CMS).
Its sole purpose is to verify that you had continuous group health plan coverage through your own or your spouse’s current employer — the exact condition that qualifies you to delay Part B without facing a financial penalty.
Without this form, Social Security cannot confirm your qualifying coverage, and you lose your right to a penalty-free enrollment.
Who Needs Medicare Form L564 — and When?
You need this form when you’re enrolling in Medicare Part B through a Special Enrollment Period, not your Initial Enrollment Period.
That specifically means you fall into one of these situations:
- You turned 65 but stayed on your employer’s group health plan because you were still working
- You were covered under your spouse’s employer group health plan past age 65
- You recently retired or lost that employer coverage and now want to enroll in Part B
- You have a disability and were covered under a large group health plan through a family member’s current employment
There is one critical timing rule: you have only eight months from the date your employer coverage ends to enroll in Part B without a penalty.
If you miss that eight-month window, you’ll need to wait for the General Enrollment Period — and you will likely face a permanent late penalty.
Why This Form Matters: The Part B Late Enrollment Penalty
The penalty for missing your Medicare Part B enrollment window is not a one-time fee — it’s a permanent addition to your monthly premium.
For every full 12-month period you could have enrolled but didn’t, Medicare adds 10% to your Part B premium — and that extra cost follows you for as long as you have Medicare.
The standard Part B premium in 2026 is $202.90 per month. Miss two full years, and you’re paying a permanent $40.58 more every single month for the rest of your life.
Medicare Form L564 exists precisely to prevent this outcome — it’s the documentation that tells the Social Security Administration you had a legitimate reason to delay.
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How to Complete Medicare Form L564: Step by Step
Completing this form is a two-person job — you handle Section A, and your employer handles Section B.
Section A: Your Responsibility
You complete Section A yourself before handing the form to your employer. Here is exactly what to fill in:
- Your full name and Social Security Number
- The employer’s name and address (the company where the group health plan originates — either yours or your spouse’s)
- The employee’s name (if coverage is through your spouse’s employer, your spouse is the “employee” and you are the “applicant”)
- The date you are completing the form
If you’ve had multiple employers since turning 65, you’ll need a separate L564 for each one.
Section B: Your Employer’s Responsibility
Once you complete Section A, pass the form to your employer’s HR department and ask them to complete Section B.
This is the part most people worry about — but for most employers, it is a routine request.
The employer confirms the following:
- Whether you were covered under the employer’s group health plan
- The start date of that group health plan coverage
- The end date of coverage (if it has already ended)
- Whether you are still employed with the company
One common employer error: HR may list the date the company switched insurance carriers rather than the actual start date of continuous group health plan coverage.
Double-check this — the date should reflect how long you’ve been covered under any group plan through that employer, not just the current policy.
Where to Submit Form L564 — and What to Send With It
You do not submit Form L564 on its own — it always travels with Form CMS-40B.
Form CMS-40B is your official Application for Enrollment in Medicare Part B.
You submit both forms together to your local Social Security Administration office. You have three options:
- By fax to 1-833-914-2016
- By mail to your local Social Security office (find yours at SSA.gov/locator)
- In person at your local SSA office
Processing typically takes two to six weeks.
Starting the process eight to ten weeks before your coverage ends gives you the best chance of a seamless transition with no gaps.
What If Your Employer Won’t Complete Section B?
This situation is more common than you’d expect — particularly for retirees whose former employer is difficult to reach.
If your employer is unable or unavailable to complete Section B, the Social Security Administration allows you to complete that section yourself, as best you can, using the records available to you. Supporting documents that can help verify your coverage dates include pay stubs, W-2 forms, health insurance cards, and official benefits enrollment confirmation letters.
In these situations, speaking with a licensed Medicare advisor before you submit gives you the best chance of getting this right the first time.
What Happens If You Miss the Eight-Month Window?
Missing the eight-month Special Enrollment Period window is a costly mistake — but it is not the end of the road.
You’ll have to wait for Medicare’s General Enrollment Period, which runs January 1 through March 31 each year.
More importantly, for every full 12-month period you were without qualifying coverage, Medicare adds a permanent 10% penalty to your monthly Part B premium.
At the 2026 standard Part B premium of $202.90, every year you delay costs you more than $240 in extra premiums each year — for life.
The right advice, at the right time, is free — and it can save you from a permanent financial penalty.
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When to Get Expert Help With Your Medicare Enrollment
Medicare enrollment has real deadlines with real financial consequences, and Form L564 is only one piece of the puzzle.
Once you’re enrolled in Part B, you’ll also want to think carefully about which Medigap supplement plan covers the gaps that Original Medicare leaves behind.
Choosing the wrong plan — or missing your Medigap Open Enrollment Period — can mean paying higher premiums or being denied coverage based on your health history.
A licensed Medicare advisor at MediGap Advisors can review your exact situation, confirm your enrollment timeline, and help you find the right supplement plan at the best available rate.
The consultation is completely free, and there is no obligation.
► Speak with a licensed Medicare advisor — get personalized help navigating your Part B enrollment at no cost to you.
Frequently Asked Questions About Medicare Form L564
Do I need Form L564 if I’m still working at 65?
Not yet.
You only need Form L564 when you’re ready to enroll in Medicare Part B through a Special Enrollment Period — typically when you retire or lose your employer group health plan coverage. While you’re still actively covered through work, you are already protected from the late enrollment penalty.
Does COBRA coverage qualify me to use Form L564?
No.
COBRA and retiree health coverage do not qualify as group health plan coverage based on current employment. If you’re on COBRA after leaving a job, your eight-month Special Enrollment Period window started the day your active employer coverage ended — not when COBRA ends. Act promptly to avoid a permanent penalty.
How long does it take to process Form L564?
Processing typically takes two to six weeks, depending on how quickly your employer completes Section B.
Starting the process eight to ten weeks before your employer coverage ends is strongly recommended to prevent any gap between your employer plan and Medicare coverage.
What if my employer goes out of business before completing the form?
If your employer is no longer in business or is otherwise unavailable, the Social Security Administration allows you to complete Section B yourself using available records.
Supporting documentation — W-2 forms, pay stubs, insurance cards, or enrollment letters — can help verify your coverage dates. A licensed Medicare advisor can guide you through this process.
Is Form L564 the same as Form CMS-40B?
No.
They are two different forms that always travel together. Form L564 is your proof of employer group health plan coverage. Form CMS-40B is the actual application to enroll in Medicare Part B. You must submit both to the Social Security Administration at the same time.
You’re More in Control Than You Think
Medicare Form L564 is not complicated — it just needs to be handled at the right time, in the right way.
Complete Section A, get your employer to complete Section B, submit both forms with your CMS-40B to the Social Security Administration within eight months of losing your employer coverage, and you are protected.
The lifetime penalty is fully avoidable. Most people who get stuck do so simply because they didn’t know the timeline or weren’t sure who to ask.
That is exactly what the advisors at MediGap Advisors are here for.
► Speak with a licensed Medicare advisor at MediGap Advisors — get personalized, no-pressure help navigating your Part B enrollment and choosing the right Medigap supplement plan.
Mike Montes is a Personal Benefits Manager at MediGap Advisors. Mike has a passion for bringing clarity to those confused about Medicare. He is an authority on Medicare, Medicare supplement plans, Medicare Advantage plans, and Part D prescription drug plans. Read more about Mike on his Bio page.