www.cms.gov Open in urlscan Pro
2a02:26f0:dc:18d::28a  Public Scan

Form analysis
2 forms found in the DOM

GET /search/cms

<form region="cms_header_secondary" action="/search/cms" method="get" id="search-block-form" accept-charset="UTF-8">
  <div class="js-form-item form-item js-form-type-search form-item-keys js-form-item-keys form-no-label">
    <label for="edit-keys--2" class="ds-c-label visually-hidden">Search</label>
    <input title="Enter the terms you wish to search for." data-drupal-selector="edit-keys" type="search" id="edit-keys--2" name="keys" value="" size="15" maxlength="128" class="form-search ds-c-field" data-once="placeholder"
      placeholder="Search CMS.gov">
  </div>
  <div data-drupal-selector="edit-actions" class="form-actions js-form-wrapper form-wrapper" id="edit-actions">
    <div class="header-search-bar">
      <input data-drupal-selector="edit-submit" type="submit" id="edit-submit--2" value="Search" class="button js-form-submit form-submit ds-c-button ds-c-button--solid">
      <i class="fas fa-search" focusable="false"></i>
    </div>
  </div>
</form>

POST https://public.govdelivery.com/accounts/USCMS/subscribers/qualify

<form aria-label="Enter your email address for email updates" accept-charset="UTF-8" action="https://public.govdelivery.com/accounts/USCMS/subscribers/qualify" id="email-footer-form" method="post"
  data-drupal-form-fields="email-footer-input,email-submit">
  <div class="ds-u-display--flex" id="email-form">
    <div class="ds-u-display--flex ds-u-flex-direction--column flex-grow">
      <label for="email" class="ds-u-font-weight--bold ds-u-margin-bottom--1">Email</label>
      <input required="required" aria-label="Enter your email address:" name="email" type="text" placeholder="you@example.com" class="ds-c-field">
    </div>
    <div class="submit-button ds-u-margin-top--2">
      <label for="email-footer-submit" class="ds-u-visibility--screen-reader">Sign up for email updates</label>
      <button id="email-submit" class="ds-c-button ds-c-button--solid cms--external-button" name="email-footer-submit" type="submit" value="Sign up">Sign up</button>
    </div>
  </div>
</form>

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CMS L564



Form #
CMS L564
Form Title
REQUEST FOR EMPLOYMENT INFORMATION
Revision Date
2020-05-26
O.M.B. #
0938-0787
O.M.B. Expiration Date
2023-06-30
Special Instructions
If you have Medicare Part A (Hospital Insurance) and you’re eligible to enroll
in Medicare Part B (Medical Insurance) through a Special Enrollment Period
(SEP), you have options for how to apply. 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. You’ll also need to send any required proof
of employment, Group Health Plan (GHP), or Large Group Health Plan (LGHP)
coverage. You can also fax your enrollment forms and evidence of employment and
health coverage to your local Social Security office. You can find your local
Social Security office by clicking “SSA Office Locator” under the “Related
Links” section below. Your employer doesn’t need to sign Section B of the CMS
L564 form. State “I want Part B coverage to begin (MM/YY)” in the remarks
section of the CMS 40B form or the online application. Visit faq.ssa.gov or call
Social Security toll-free at 1-800-772-1213 (TTY 1-800-325-0778) for more
information. NOTE: If you don’t already have Part A you can apply online at
SSA.gov/benefits/medicare.


DOWNLOADS

 * CMS L564E (PDF)
 * CMS L564S (PDF)


RELATED LINKS

 * CMS Form L-564 - English - HTML
 * CMS Form L-564 - Spanish - HTML
 * Apply for Medicare Part B Online During a Special Enrollment Period
 * SSA Office Locator
 * CMS Accessibility & Nondiscrimination for Individuals with Disabilities
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