Social Security Form Omb No 0938 0787 Printable The valid OMB control number for this information is 0938 0787 The time required to complete this information collection is estimated to average 15 minutes per response including the time to review instructions search existing data resources gather the data needed and complete and review the information collection
OMB No 0938 0787 Expires 06 2023 WHAT IS THE PURPOSE OF THIS FORM In order to apply for Medicare in a Special Enrollment Period you must have or had group health plan coverage within the last 8 months through your or your spouse s current employment 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
Social Security Form Omb No 0938 0787 Printable
Social Security Form Omb No 0938 0787 Printable
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OMB No 0938 0787 SECTION B To be completed by Employers For Employer Group Health Plans ONLY 1 Is or was the applicant covered under an employer group health plan Yes No 2 If yes give the date the applicant s coverage began mm yyyy 3 Has the coverage ended Yes No 4 If yes give the date the coverage ended mm yyyy 5 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
1 Need and Legal Basis Section 1837 i of the Social Security Act the Act provides for a SEP for individuals who delay enrolling in Medicare Part B because they are covered by a group health plan based on their own or a spouse s current employment status DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES REQUEST FOR EMPLOYMENT INFORMATION SECTION A To be completed by individual signing up for Medicare Part B Medical Insurance Form Approved OMB No 0938 0787 I Employer s Name 3 Employer s Address City 4 Applicant s Name 6
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Form CMS L564 Form Title REQUEST FOR EMPLOYMENT INFORMATION Revision Date 2023 09 30 O M B 0938 0787 O M B Expiration Date 2024 10 31 Special Instructions 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
Your Medicare Number Your current address and phone number WHAT HAPPENS NEXT Send your completed and signed application to your local Social Security office If you have questions call Social Security at 1 800 772 1213 TTY users should call 1 800 325 0778 HOW DO YOU GET HELP WITH THIS APPLICATION Download a form learn more about a letter you got in the mail or find a publication like filing a claim or appealing a coverage decision Find Forms Publications Read print or order free Medicare publications in a variety of formats Get Publications Mailings 7500 Security Boulevard Baltimore MD 21244
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The valid OMB control number for this information is 0938 0787 The time required to complete this information collection is estimated to average 15 minutes per response including the time to review instructions search existing data resources gather the data needed and complete and review the information collection
https://medicarehbs.com/wp-content/uploads/2021/12/CMS-L564E-and-40B.pdf
OMB No 0938 0787 Expires 06 2023 WHAT IS THE PURPOSE OF THIS FORM In order to apply for Medicare in a Special Enrollment Period you must have or had group health plan coverage within the last 8 months through your or your spouse s current employment
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Social Security Form Omb No 0938 0787 Printable - DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES REQUEST FOR EMPLOYMENT INFORMATION SECTION A To be completed by individual signing up for Medicare Part B Medical Insurance Form Approved OMB No 0938 0787 I Employer s Name 3 Employer s Address City 4 Applicant s Name 6
