Form CMS L564 / R297

Form CMS-L564 is used to request proof of group health plan coverage from an employer. It supports a Medicare Special Enrollment Period application by confirming current employment and health coverage dates. The employee completes the first section, then the employer fills in coverage and employment details and signs the form. The completed form is submitted along with the Application for Enrollment in Medicare (CMS-40B) to the Social Security office.

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