Form CMS-L564 is an employment information form from the Social Security Administration (SSA). It’s used in conjunction with Form CMS-40B when you apply for Medicare part B during a special ...

If you are enrolling during a Special Enrollment Period (SEP) due to loss of employer coverage, you will need to attach the ...

If you’re applying during an SEP, then you will need to submit an additional form along with CMS-40b. This additional form is CMS-L564, and you must fill it out and include it with your application.