Form Approved OMB No. 0938-0787 Expires: 10/2024. REQUEST FOR EMPLOYMENT INFORMATION. WHAT IS THE PURPOSE OF THIS FORM? In order to apply for Medicare in a Special Enrollment Period, you must have or had group health plan coverage within the last 8 months through your or your spouse’s current employment. People with disabilities must have …

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information is 0938-0787.

Form Approved OMB No. 0938-0787. REQUEST FOR EMPLOYMENT INFORMATION. WHAT IS THE PURPOSE OF THIS FORM? In order to apply for Medicare in a Special Enrollment Period, you must have or had group health plan coverage within the last 8 months through your or your spouse’s current employment. People with disabilities must have large

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The valid OMB control number for this information is 0938-0787. The time required to complete this information collection is estimated to average 15 minutes per response, including the time to review instructions, search existing data resources, gather the

Use this form to show proof of group health plan coverage based on current employment so you can enroll in Medicare. You complete Section A of this form, then ask your employer to fill out Section B.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information is 0938-0787.

The latest form for Request for Employment Information (CMS-R-297/CMS-L564) expires 2023-06-30 and can be found here.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO.0938-0787 REQUEST FOR EMPLOYMENT INFORMATION FORM CMS-L564 (4-2000) Dear Sir/Madam: We need the following information regarding the above claimant. Please answer the questions below, sign and date this letter …

Download a form, learn more about a letter you got in the mail, or find a publication. What do you want to do? Get Medicare forms for different situations, like filing a claim or appealing a coverage decision. Read, print, or order free Medicare publications in a variety of formats. Find out what to do with Medicare information you get in the mail.