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  • 01mk56600414special Enrollment Period Form

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P.O. Box 98029 Baton Rouge Louisiana 708989029 Phone 800/5992583 Fax 225/2952054Special Enrollment Form Individual OffExchange This form is to be completed and submitted with the individual application.

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Phone: Call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. En español: Llame a SSA gratis al 1-800-772-1213 y oprima el 2 si desea el servicio en español y espere a que le atienda un agente. In person: Your local Social Security office.

In person: Your local Social Security office. For an office near you check .ssa.gov.

The Part B SEP starts when you have coverage from current work (job-based insurance) and you are in your first month of eligibility for Part B. It ends eight months after you lose coverage from current employment because the employment or insurance ends.

Employees who do not enroll in Medicare upon reaching age 65 should enroll in Medicare upon retirement. This enrollment during the SEP will include the Form CMS-L564 that is used for proof of group health plan coverage based on current employment (i.e., active coverage).

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 enrollment period (SEP). One portion is completed by you and the other is completed by your employer or your spouse's employer.

You can complete the Part B SEP online or you can mail your completed CMS 40B, Application for Enrollment in Medicare - Part B (Medical Insurance) and CMS L564 - Request for Employment Information to your local Social Security office.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Content Takedown Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
+1 833 426 79 33
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232