Needed Forms
CMS-L564 – Employer Form to Prove Prior Coverage
What is this form?
The CMS-L564 form is used to verify that you had health insurance through your employer (or your spouse’s employer) while delaying Medicare Part B enrollment. Your employer completes part of the form to confirm your coverage dates and employment status. This documentation helps you qualify for a Special Enrollment Period and avoid Medicare late enrollment penalties when signing up for Part B.
Who typically needs it?
- Individuals working past age 65 who delayed Part B
- Retirees who recently lost employer coverage
- Anyone enrolling in Part B through a Special Enrollment Period after having employer-sponsored health coverage
CMS-40B – Application for Enrollment in Medicare Part B
What is this form?
The CMS-40B form is the application used to enroll in Medicare Part B (Medical Insurance). It is commonly submitted by people who already have Medicare Part A and are now ready to add Part B coverage. Use this if you are not enrolling online at SSA.gov and are faxing or dropping it off to your local office. Many individuals use this form when retiring, losing employer coverage, or enrolling during a Special Enrollment Period.
Who typically needs it?
- People enrolling in Part B after delaying coverage while working and have Part A
- Beneficiaries who have Part A and need to activate Part B coverage
CMS-40B – Application for Enrollment in Medicare Part B
What is this form?
The CMS-40B form is the application used to enroll in Medicare Part B (Medical Insurance). It is commonly submitted by people who already have Medicare Part A and are now ready to add Part B coverage. Use this if you are not enrolling online at SSA.gov and are faxing or dropping it off to your local office. Many individuals use this form when retiring, losing employer coverage, or enrolling during a Special Enrollment Period.
Who typically needs it?
- People enrolling in Part B after delaying coverage while working and have Part A
- Beneficiaries who have Part A and need to activate Part B coverage
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