Article Guide
The CMS L564/R297 form serves as an essential tool for individuals seeking to establish their eligibility for Medicare Part B coverage. Understanding this form is crucial for those who are transitioning from employer-sponsored health insurance to Medicare or who are experiencing a change in their health insurance status. This process can impact healthcare access and financial well-being. The form requires detailed information regarding the individual’s prior health coverage, including dates of employment and specifics about the employer’s health plan. By capturing this information accurately, the form helps facilitate a smooth transition to Medicare, ensuring that individuals maintain continuous healthcare coverage and avoid potential gaps in benefits. Timeliness is key, as delays in submission can lead to significant challenges in securing essential medical services. Recognizing the importance of this form can empower individuals to navigate the often-complex world of Medicare with confidence and clarity.
Form Sample
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Form Approved |
DEPARTMENT OF HEALTH AND HUMAN SERVICES |
OMB No. |
CENTERS FOR MEDICARE & MEDICAID SERVICES |
Expires: 06/2023 |
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 group health plan coverage based on your, your spouse’s or a family member’s current employment.
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.
HOW IS THE FORM COMPLETED?
•Complete the first section of the form so that the employer can find and complete the information about your coverage and the employment of the person through which you have that health coverage.
•The employer fills in the information in the second section and signs at the bottom.
WHAT DO I DO WITH THE FORM?
Fill out Section A and take the form to your employer. Ask your employer to fill out Section B. You need to get the completed form from your employer and include it with your Application for Enrollment in Medicare
GET HELP WITH THIS FORM
•Phone: Call Social Security at
•En español: Llame a SSA gratis al
•In person: Your local Social Security office. For an office near you check www.ssa.gov.
You have the right to get Medicare information in an accessible format, like large print, Braille, or audio. You also have the right to file a complaint if you feel you’ve been discriminated against. Visit
Form CMS L564/R297 (08/20) |
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DEPARTMENT OF HEALTH AND HUMAN SERVICES |
Form Approved |
CENTERS FOR MEDICARE & MEDICAID SERVICES |
OMB No. |
REQUEST FOR EMPLOYMENT INFORMATION
SECTION A: To be completed by individual signing up for Medicare Part B (Medical Insurance)
1.Employer’s Name
3.Employer’s Address
2. Date
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4.Applicant’s Name
6.Employee’s Name
5.Applicant’s Social Security Number
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7.Employee’s Social Security Number
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SECTION B: To be completed by Employers
For Employer Group Health Plans ONLY:
1. Is (or was) the applicant covered under an employer group health plan? |
Yes |
No |
2.If yes, give the date the applicant’s coverage began. (mm/yyyy)
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3. Has the coverage ended? |
Yes |
No |
4.If yes, give the date the coverage ended. (mm/yyyy)
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5.When did the employee work for your company?
From: (mm/yyyy)
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To: (mm/yyyy)
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Still Employed: (mm/yyyy)
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6.If you’re a large group health plan and the applicant is disabled, please list the timeframe (all months) that your group health plan was primary payer.
From: (mm/yyyy)
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To: (mm/yyyy)
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For Hours Bank Arrangements ONLY:
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Is (or was) the applicant covered under an Hours Bank Arrangement? |
Yes |
No |
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2. |
If yes, does the applicant have hours remaining in reserve? |
Yes |
No |
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3.Date reserve hours ended or will be used? (mm/yyyy)
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All Employers:
Signature of Company Official
Date Signed
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Title of Company Official
Phone Number
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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
Form CMS L564/R297 (08/20) |
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Form Approved
OMB No.
STEP BY STEP INSTRUCTIONS FOR THIS FORM
SECTION A:
The person applying for Medicare completes all of Section A.
1.Employer’s name:
Write the name of your employer.
2.Date:
Write the date that you’re filling out the Request for Employment Information form.
3.Employer’s address:
Write your employer’s address.
4.Applicant’s Name: Write your name here.
5.Applicant’s Social Security Number: Write your Social Security Number here.
6.Employee’s Name:
If you get group health plan coverage based on your employment, write your name here. If you get group health plan coverage through another person, like a spouse or family member, write their name.
7.Employee’s Social Security Number:
If you get group health plan coverage based on your employment, write your Social Security Number here. If you get group health plan coverage through another person, like a spouse or family member, write their Social Security Number.
Once you complete Section A:
Once Section A is completed, give this form to your employer to complete Section B. Once Section B has been completed
by your employer, return this form along with your Part B application to your local Social Security office.
SECTION B:
The employer completes all of Section B.
If you’re an employer without an hours bank arrangement, complete the section called “For Employer Group Health Plans ONLY”
1.Is (or was) the applicant covered under an employer group health plan?
Please check yes or no if the applicant was covered under your group health plan offered by your company. The applicant may be the employee or another person related to the employee, such as a spouse or family member with disabilities. If your company doesn’t offer a group health plan, please check No. A group health plan is any plan of one or more employers to provide health benefits or medical care (directly or otherwise) to current or former employees, the employer, or their families.
2.If yes, give the date the coverage began.
Write the month and year the date the applicant’s coverage began in your group health plan.
3.Has the coverage ended?
Check yes or no if the group health plan coverage for the applicant has ended.
4.If yes, give the date the coverage ended.
Write the month and year the group health plan coverage ended for the applicant.
5.When did the employee work for your company?
Write the start and end dates of the employment for the employee in which the applicant is related. It may be the applicant or another person related to the employee, such as a spouse or family member with disabilities.
Enter the month and year of the start of the employment in the “From” box.
Enter the month and year of end of the employment in the “To” box.
If the employee is still employed, enter the month and year of the current date.
Current employment is active working status. It is not disability or retirement.
6.If you’re a large group health plan and the applicant is disabled, please list the timeframe (all months) that your group health plan was primary payer.
Write the start and end dates that your group health plan was primary payer for the applicant.
If you’re an employer with an hours bank arrangement, complete the section called “For Hours Bank Arrangements ONLY”
1.Is (or was) the applicant covered under an hours bank arrangement?
Please check yes or no if the applicant was covered under an hours bank arrangement. If you check no, please also fill out the section for “Employer Group Health Plans ONLY”.
2.If yes, does the applicant have hours remaining in reserve?
Please indicate if the applicant currently has health coverage based on the remaining hours in the employee’s hours bank account.
3.Date reserve hours ended or will be used?
Please write the month and year for when the remaining hours in the employee’s hours bank account expired or will expire.
All employers need to complete the bottom of Section B.
•Signature of Company Official:
An official representative of the company needs to sign this document. Please do not print.
•Date Signed:
Write the date that you sign the form in this field.
•Title of Company Official:
Print the title of the company official who signed the form in this field.
•Phone Number:
Write the phone number of the company official who signed the form in this field. If there are questions regarding the information on this form, a representative from Social Security will contact you.
INSTRUCTIONS: Form CMS L564/R297 (08/20) |
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Document Specifications
| Fact Name | Details |
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| Purpose | The CMS L564/R297 form is used to document coverage under a group health plan. |
| Eligibility | This form allows individuals to qualify for a Special Enrollment Period when transitioning to Medicare. |
| Submission | It must be submitted to the Centers for Medicare & Medicaid Services (CMS) and can often be completed online or via mail. |
| State-Specific Regulations | Dependent on state laws, additional requirements may apply for local health insurance programs. |
| Information Required | Required details usually include personal identification information, group health plan information, and coverage dates. |
| Timeframe | The form should be completed and submitted promptly to avoid gaps in coverage and ensure timely enrollment. |
Steps to Filling Out CMS L564/R297
Completing the CMS L564/R297 form is an important step for those who need to document a qualifying event for health insurance post-enrollment. After filling out this form, it is typically submitted to the appropriate health insurance provider or agency for processing.
- Start by obtaining the CMS L564/R297 form. You can usually download it from the official website of the Centers for Medicare & Medicaid Services (CMS).
- Carefully read any instructions accompanying the form to understand the specific requirements.
- Provide your personal information at the top of the form. This includes your full name, address, Social Security number, and date of birth.
- Indicate the reason for filling out the form. This might involve selecting a specific qualifying event, such as loss of coverage or other relevant circumstances.
- Fill out any required details related to the qualifying event, such as the effective date of the event and the name of the previous insurance provider.
- Include information about any dependents if applicable. This includes their names and relationships to you.
- Review the completed form for accuracy. Ensure all sections are filled out completely and correctly.
- Sign and date the form, confirming that all information provided is true and accurate to the best of your knowledge.
- Make a copy of the completed form for your records before submission.
- Submit the original form as directed, which may involve mailing it to a specified address or delivering it in person.
More About CMS L564/R297
What is the CMS L564/R297 form?
The CMS L564/R297 form, also known as the Request for Employment Information, is a document used by individuals applying for Medicare. It helps to determine eligibility for Medicare based on current or previous employment. This form can be particularly important for those who are turning 65 or who are eligible due to disability or specific life circumstances. Completing it accurately ensures that the Social Security Administration can assess your situation appropriately.
Who needs to fill out the CMS L564/R297 form?
Generally, this form is filled out by individuals approaching Medicare eligibility. This can include those who are elderly, disabled, or have special circumstances. If you have recently aged into Medicare or are seeking benefits based on your work history, you will likely need to submit this form, along with other required documentation, to establish your eligibility for coverage.
Where can I obtain the CMS L564/R297 form?
You can easily obtain the CMS L564/R297 form from the official Centers for Medicare & Medicaid Services (CMS) website. It is available for download in PDF format, allowing you to print it out, fill it in, and submit it as needed. Alternatively, you may also contact your local Social Security Administration office to request a copy or guidance on completing the form.
How do I fill out the CMS L564/R297 form correctly?
Filling out the form involves providing accurate information regarding your employment history, including the names of employers, dates of employment, and your role. Make sure you double-check any personal information such as your name and Social Security number to avoid delays. Clear and accurate details will facilitate the evaluation process. Once complete, review it one last time for any errors before submission.
What happens after I submit the CMS L564/R297 form?
After submitting the form, it will undergo review by the Social Security Administration. They will assess the information provided to determine your Medicare eligibility. This process may take some time, so be prepared for a wait. You may also be contacted for clarification or additional information, so stay vigilant about checking your communication channels.
Can I file the CMS L564/R297 form electronically?
As of now, the CMS L564/R297 form is primarily submitted via mail or in-person at your local Social Security Administration office. While digital submissions may be a feature in the future, check for any updates on the CMS website or with your local office. For now, ensure that you send it in with sufficient time for your eligibility to be processed before your Medicare coverage begins.
Common mistakes
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Inaccurate Personal Information: Many individuals fail to double-check their personal information, such as their name, date of birth, and Social Security number. Errors in these details can lead to delays in processing your application.
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Missing Signatures: Some applicants overlook the requirement for signatures. Failing to sign the form can result in rejection or additional requests for information, prolonging the process.
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Incomplete Sections: A common mistake is leaving sections of the form blank. Ensure that all relevant fields are filled out, even if information seems minor. Incomplete forms may be dismissed or returned for additional information.
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Incorrect Submission Method: Applicants sometimes submit the form incorrectly, not following the specific instructions for filing. Familiarize yourself with submission guidelines to avoid unnecessary complications.
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Not Keeping Copies: Too often, individuals neglect to keep copies of their submitted forms. Retaining a copy can provide a reference and assist in tracking the processing status, should any issues arise.
Documents used along the form
The CMS L564/R297 form is commonly used in various situations. When dealing with this form, several other documents may also be necessary to ensure your application is complete. Here’s a brief overview of four documents that often accompany the CMS L564/R297 form.
- Proof of Employment: This document provides evidence of your current employment status. It can be in the form of a pay stub, an employment letter, or a recent tax return showing income.
- Identification Documents: A copy of your driver's license, state ID, or passport may be required to verify your identity. These documents help ensure that the application is connected to the correct person.
- Proof of Residency: Utility bills, bank statements, or lease agreements can serve as proof of where you live. This information helps confirm that you meet residency requirements.
- Other Health Insurance Documents: If you have other health coverage, submitting the relevant policies or cards can be important. This information assists in understanding your overall healthcare needs.
Gathering these documents when submitting the CMS L564/R297 form can streamline the process and help avoid any delays in your application. Each piece of documentation plays a crucial role in making sure everything is in order.
Similar forms
The CMS L564/R297 form is similar to the IRS Form 4506-T, which allows individuals to request a transcript of their tax return. Just as the CMS L564/R297 form is utilized to confirm health coverage with Medicare, the 4506-T enables taxpayers to verify their income and tax status. It serves as a verification tool for various situations, such as when applying for loans or government assistance programs, ensuring that individuals can provide accurate financial information when necessary.
Another document comparable to the CMS L564/R297 form is the Social Security Administration’s Form SSA-1099. This form shows the amount of Social Security benefits received in a given year, helping individuals declare income for health insurance or Medicare eligibility. Like the CMS L564/R297 form, which is essential for confirming past health coverage, the SSA-1099 plays a critical role in establishing financial eligibility for various benefits.
The Medicaid application is also similar in its purpose. When seeking Medicaid coverage, applicants must provide proof of their previous health insurance or other coverage types. This helps the state verify the applicant's eligibility based on current and prior coverage, similar to how the CMS L564/R297 form ensures accurate reporting of health status to Medicare. This documentation is vital to streamline the application process and assess needs appropriately.
In the realm of health insurance, the Summary of Benefits and Coverage (SBC) document also presents similarities. The SBC provides a concise overview of what a health plan covers and the costs involved, which is crucial when making decisions about healthcare. While the CMS L564/R297 form focuses on verifying eligibility and past coverage, the SBC acts as an informative guide that can significantly impact an individual’s choice of health plan.
The Acknowledgment of Health Coverage (AHC) is another relevant document. This form is often used by employers to confirm that their employees have health insurance coverage. In much the same way as the CMS L564/R297 form, the AHC serves to validate health coverage status for employees seeking to enroll in Medicare or other healthcare options, facilitating smoother transitions between different health care systems.
Lastly, the Coverage Area Application (CAA) is utilized in scenarios where individuals need to demonstrate eligibility for certain health benefits. Through this application, applicants provide information similar to that of the CMS L564/R297 form, establishing prior health coverage. This process is vital for ensuring continuity of care and understanding available health services, addressing both the individual's needs and the requirements set forth by health benefit providers.
Dos and Don'ts
When filling out the CMS L564/R297 form, attention to detail is crucial. Mistakes can lead to delays in enrollment or even denial of coverage. Here are four important dos and don'ts to keep in mind.
- Do read the instructions carefully before starting the form.
- Do make sure all personal information is accurate and up-to-date.
- Don’t leave any required fields blank; incomplete forms may be rejected.
- Don’t rush through the process; take your time to ensure everything is correct.
Misconceptions
The CMS L564/R297 form is often misunderstood. Below are seven common misconceptions about this form, along with clarifications.
- The form is only for Medicare beneficiaries. Many believe that the L564/R297 is exclusive to Medicare recipients. However, it is used by various individuals qualifying for hospital services under certain conditions.
- It is only required for enrollment. While the form may be linked to enrollment, it can also be necessary for verifying eligibility for other healthcare benefits.
- You cannot submit the form online. Some think that the only way to complete the L564/R297 is by mailing a physical copy. In fact, many options exist for submission, including online capabilities in certain cases.
- The form guarantees coverage. It is a common belief that submitting this form automatically ensures coverage. In reality, it supports the process but does not guarantee approval.
- The information required is minimal. Many underestimate the amount of information needed. The form requires detailed data about previous health insurance coverage that may not always be readily available.
- The processing time is always quick. Some individuals expect rapid processing. However, the timeframe for approval can vary widely based on different factors, including the completeness of submission.
- Once submitted, you cannot make changes. It is a misconception that once the form is submitted, it is final. Applicants typically have the ability to correct or update information if necessary.
Key takeaways
Filling out the CMS L564/R297 form is an important step in the process of coordinating health care coverage through Medicare. Below are key takeaways to guide you through the use of this form:
- Understanding the Purpose: The CMS L564 form is used to verify eligibility for premium assistance under Medicare.
- Completing the Form: Accurate information is crucial. Make sure all required personal details are filled in completely.
- Documentation: Attach necessary documents that prove your eligibility, such as proof of income or other relevant paperwork.
- Submission Process: Be aware of where and how to submit the completed form. Generally, it can be sent to your local Medicare office.
- Timeliness: Submit the form as soon as possible to avoid delays in your Medicare coverage.
- Tracking Your Submission: After sending the form, keep a copy for your records. This is important for tracking your status.
- Seek Assistance: If you encounter difficulties, don't hesitate to seek help from Medicare representatives or local organizations.
- Updates and Changes: Stay informed of any changes to the form or its requirements, as policies may evolve over time.
These takeaways can help ensure that you navigate the process effectively, minimizing potential confusion and obstacles.