Medicare Form L564 protects you from a lifelong Part B penalty. Completing it is simpler than most people think.
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 cannot confirm your qualifying coverage. It also has no reason to waive the penalty. You would otherwise owe it for each 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 helps you enroll in Medicare Part B during a Special Enrollment Period. It can also help you avoid a penalty.
Officially titled the “Request for Employment Information,” the CMS L564 form is a two-section document. The Centers for Medicare & Medicaid Services (CMS) issues it.
Its only purpose is to confirm you had continuous group health plan coverage through your employer or your spouse’s. This is the exact condition that lets you delay Part B without a financial penalty.
Without this form, Social Security cannot confirm your coverage. You may lose your right to enroll without a penalty.
Who Needs Medicare Form L564 and When?
You need this form when you enroll in Medicare Part B during a Special Enrollment Period. Do not use it for 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. A large group health plan covered you. This coverage was through a family member’s current job
One key timing rule exists. You have **eight months** to sign up for **Part B** after your employer coverage ends. If you do not sign up within those eight months, you may have to pay a penalty.
If you miss that eight-month window, you must wait for the General Enrollment Period. You will likely face a permanent late penalty.
Why This Form Matters: The Part B Late Enrollment Penalty
Missing your Medicare Part B enrollment window has a penalty. This is not a one-time fee, it is a permanent increase to your monthly premium.
For each full 12-month period you could have enrolled but didn’t, Medicare adds 10% to your Part B premium. That extra cost stays for as long as you have Medicare.
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 to prevent this outcome. It documents that you had a valid reason to delay. It tells the Social Security Administration why you delayed.
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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 CMS L564 form 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 changed insurance carriers. They may not list the actual start date of continuous group health coverage.
Double-check this. The date should show how long you’ve had coverage under any group plan with that employer. Not just the current policy.
Where to Submit CMS L564 Form and What to Send With It
You do not submit CMS L564 form 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 cannot or is not available to complete Section B, you may complete it yourself. You should do this as best you can, using the records you have. Supporting documents that can verify your coverage dates include pay stubs and W-2 forms. They also include 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 each full 12-month period without qualifying coverage, Medicare adds a permanent 10% penalty. This penalty increases your monthly Part B premium.
The right advice, at the right time, is free, 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 enroll in Part B, think about which Medigap plan covers the gaps in Original Medicare.
Choosing the wrong plan, or missing your Medigap Open Enrollment Period, can raise your premiums. It can also lead to a denial based on your health history.
A licensed Medicare advisor at MediGap Advisors can review your situation. They can confirm your enrollment timeline. They can also help you find the right supplement plan at the best 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 want to enroll in Medicare Part B. Use it during a Special Enrollment Period. This is usually when you retire. It can also be when you lose your employer group health plan coverage. Your work coverage already protects you 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 are on COBRA after you leave a job, you may have an eight-month Special Enrollment Period. It starts when your active employer coverage ends. It does not start 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.
Start the process eight to ten weeks before your employer coverage ends. This helps 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, you may fill out Section B yourself. Use any records you have.
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 form to sign up for Medicare Part B.
You must send both forms to the Social Security Administration together.
What is Form HCFA L564?
Form HCFA L564 is the older name for Form CMS-L564, the Request for Employment Information. It uses the HCFA label because the Centers for Medicare & Medicaid Services had a different name. The agency used the name Health Care Financing Administration until 2001.
Your employer fills out the form to confirm you had group health coverage through your current job after you became eligible for Medicare. You submit it to Social Security with Form CMS-40B. This lets you enroll in Medicare Part B during a Special Enrollment Period. It also helps you avoid a late enrollment penalty.
You’re More in Control Than You Think
Medicare Form L564 isn’t complicated; you just need to handle it at the right time, in the right way.
Complete Section A. Ask your employer to complete Section B. Submit both forms with your CMS-40B. Send everything to the Social Security Administration within eight months of losing employer coverage.
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 with Part B enrollment. Choose the right Medigap supplement plan for your needs.
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.