If you are an individual representative payee with a my social security account you should check out our new representative payee portal.
Social security part b employer form.
One portion is completed by you and the other is completed by your employer or your spouse s employer.
Many forms must be completed only by a social security representative.
Social security and the centers for medicare medicaid services cms need your information to determine if you.
Once section b has been completed by your employer return this form along with your part b application to your local social security office.
Visit faq ssa gov or call social security to free at 1 800 772 1213 tty 1 800 325 0778 for more information.
Once section b has been completed by your employer return this form along with your part b application to your local social security office.
State i want part b coverage to begin mm yy in the remarks section of the cms 40b form or the online application.
The employer completes all of section b.
You will need to sign up for it during your initial enrollment period or you will pay a penalty.
Form cms l564 is an employment information form from the social security administration ssa.
The benefit you receive from us.
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.
Please call us at 1 800 772 1213 tty 1 800 325 0778 monday through friday between 8 a m.
To sign up please call our toll free number at 1 800 772 1213 tty 1 800 325 0778 you also may contact your local social security office.
It s used in conjunction with form cms 40b when you apply for medicare part b during a special enrollment period sep.
What is form cms l564.
Your employer doesn t need to sign section b of the cms l564 form.
The social security act as amended 42 u s c.
Your name date of birth and.
If you re an employer without an hours bank.
Or contact your local social security office.
Social security and the centers for medicare medicaid services cms need your information to determine if you re entitled to part b.
If you live in puerto rico you will not receive medicare part b medical insurance automatically.
If you re an employer without an hours bank arrangement complete the section called for employer group health plans only.
1395o 1395s and 1395ii for your enrollment in medicare part b.
If you are already enrolled in medicare part a and you would like to enroll in part b please complete form cms 40b application for enrollment in medicare part b medical insurance if you are applying for medicare part b due to a loss of employment or group health coverage you will also need to complete form cms l564 request for employment information.
The form you are looking for is not available online.
1395o 1395s and 1395ii for your enrollment in medicare part b.
A social security benefit verification letter includes.
