How do I fill out a CMS-L564 form?

SECTION A: Employer's name: Write the name of your employer. Date: Write the date that you're filling out the Request for Employment Information form. Employer's address: Write your employer's address. Applicant's Name: ... Applicant's Social Security Number: ... Employee's Name: ... Employee's Social Security Number:

US Legal Forms
Application
Employment Information Form

Request For Employment Information Form Cms-l564

Q: How do I fill out a CMS-L564 form?

SECTION A: Employer&#039;s name: Write the name of your employer. Date: Write the date that you&#039;re filling out the Request for Employment Information form. Employer&#039;s address: Write your employer&#039;s address. Applicant&#039;s Name: ... Applicant&#039;s Social Security Number: ... Employee&#039;s Name: ... Employee&#039;s Social Security Number:

Category:

Employment - Personnel Files

State:

Multi-State

Control #:

US-449EM

Format:

Instant download

Description

This Employment & Human Resources form covers the needs of employers of all sizes.

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How to fill out Employment Information Form?

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FAQ

You can complete form CMS-40B (Application for Enrollment in Medicare ? Part B [Medical Insurance]) and CMS-L564 (Request for Employment Information) online. You can also fax the CMS-40B and CMS-L564 to 1-833-914-2016; or return forms by mail to your local Social Security office.

This form is used for proof of group health care coverage based on current employment. This information is needed to process your Medicare enrollment application. The employer that provides the group health plan coverage completes the information about your health care coverage and dates of employment.

SECTION A: Employer's name: Write the name of your employer. Date: Write the date that you're filling out the Request for Employment Information form. Employer's address: Write your employer's address. Applicant's Name: ... Applicant's Social Security Number: ... Employee's Name: ... Employee's Social Security Number:

You need to contact your HR representative and inform them that the law requires them to sign the form and if they refuse not only will you be forced to sue, but you will report them to the Social Security Administration for investigation in refusing to comply with the federal regulations that the employer fill out the ...