Printable Social Security Form Omb No 0938 0787 GET HELP WITH THIS FORM Phone Call Social Security at 1 800 772 1213 Form Approved OMB No 0938 0787 REQUEST FOR EMPLOYMENT INFORMATION SECTION A To be completed by individual signing up for Medicare Part B Medical Insurance 1 Employer s name Download and print to PDF Note
Social Security Administration Telephone Number Employer s Name and Address Date The valid OMB control number for this information is 0938 0787 The time required to complete this information suggestions for improving this form please write to CMS 7500 Security Boulevard Attn PRA Reports Clearance Oficer Mail Stop C4 26 05 Form Approved OMB No 0938 0787 REQUEST FOR EMPLOYMENT INFORMATION SECTION A To be completed by individual signing up for Medicare Part B Medical Insurance 1 Employer s Name 2 Date 3 Employer s Address City State Zip Code 4 Applicant s Name 5 Applicant s Social Security Number 6 Employee s Name 7 Employee s
Printable Social Security Form Omb No 0938 0787
Printable Social Security Form Omb No 0938 0787
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Social Security is authorized to collect your information under sections 1836 1840 and 1872 of the Social Security Act as amended 42 U S C 1395o 1395s and 1395ii for your enrollment in Medicare Part B Social Security and the Centers for Medicare Medicaid Services CMS need your information to determine if you re entitled to Part B OMB 0938 0787 OMB report HHS CMS of the Social Security Act The Act and or qualify for a reduction in the premium amount under the provisions of section 1839 b of the Act The latest form for Request for Employment Information CMS R 297 CMS L564 expires 2023 06 30 and can be found here
Form Approved OMB No 0938 0769 Employee s Name Employer s Name Employer s Address Claimant s Name Claimant s Social Security Number We need the information listed below in connection with 1 Is the claimant receiving retirement payments based on his her own State or Form Approved OMB No 0938 0787 REQUEST FOR EMPLOYMENT INFORMATION SECTION A To be completed by individual signing up for Medicare Part B Medical Insurance 1 Employer s Name 2 Date 3 Employer s Address City State Zip Code 4 Applicant s Name 5 Applicant s Social Security Number 6 Employee s Name 7 Employee s
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Form Approved OMB No 0938 0787 I Employer s Name 3 Employer s Address City 4 Applicant s Name 6 Emp oyee s Name SECTION B To be completed by Employers For Employer Group Health Plans ONLY I Is or was the applicant covered under an employer group health plan 2 If yes give the date the applicant s coverage began mm yyyy 3 The form you are looking for is not available online Many forms must be completed only by a Social Security Representative Please call us at 1 800 772 1213 TTY 1 800 325 0778 Monday through Friday between 8 a m and 5 30 p m or contact your local Social Security office
The form CMS L564 also referred to as CMS R 297 is used in conjunction with form CMS40B Application for Supplementary Medical Insurance during an individual s special enrollment period SEP Completed by an employer the CMS L564 provides proof of an applicant s employer group health coverage The Social Security Administration SSA OMB No 0938 0787 CENTERS FOR MEDICARE MEDICAID SERVICES REQUEST FOR EMPLOYMENT INFORMATION or suggestions for improving this form please write to CMS 7500 Security Boulevard N2 14 26 Baltimore Maryland 21244 1850 Form CMS L564 4 2000 PRINT SOCIAL SECURITY NUMBER HOLDERS NAME IF DIFFERENT FROM YOURS 6 MAILING ADDRESS NUMBER
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https://www.cms.gov/cms-l564-request-employment-information
GET HELP WITH THIS FORM Phone Call Social Security at 1 800 772 1213 Form Approved OMB No 0938 0787 REQUEST FOR EMPLOYMENT INFORMATION SECTION A To be completed by individual signing up for Medicare Part B Medical Insurance 1 Employer s name Download and print to PDF Note
https://secure.ssa.gov/apps10/poms/images/Other/G-CMS-L564.pdf
Social Security Administration Telephone Number Employer s Name and Address Date The valid OMB control number for this information is 0938 0787 The time required to complete this information suggestions for improving this form please write to CMS 7500 Security Boulevard Attn PRA Reports Clearance Oficer Mail Stop C4 26 05
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Printable Social Security Form Omb No 0938 0787 - OMB 0938 0787 OMB report HHS CMS of the Social Security Act The Act and or qualify for a reduction in the premium amount under the provisions of section 1839 b of the Act The latest form for Request for Employment Information CMS R 297 CMS L564 expires 2023 06 30 and can be found here
