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The CMS L564/R297 form serves as an essential tool for individuals seeking to enroll in Medicare Part B, particularly during special circumstances such as loss of employer-sponsored health insurance. Designed to facilitate a smoother transition to Medicare, the form helps capture critical information regarding the enrollee's prior health coverage, ensuring that appropriate coverage begins without unnecessary gaps. By collecting essential details such as the individual's personal information, the type of previous insurance coverage, and the termination date of that coverage, the form lays the groundwork for verification processes. It plays a pivotal role not only in the enrollment process but also in safeguarding potential Medicare benefits. Clear instructions accompany the form, guiding the user through required documentation and submission methods, thereby making it accessible to a wide range of applicants. Understanding the nuances of the CMS L564/R297 form can significantly aid individuals in navigating the complexities of Medicare enrollment.
CMS L564/R297 Example
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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:
1. |
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) |
2 |
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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File Breakdown
| Fact Name | Description |
|---|---|
| Purpose | The CMS L564/R297 form is used to verify eligibility for Medicare Part A and/or Part B, typically used by individuals applying for coverage. |
| Eligibility | Individuals who are turning 65 or are disabled may need to submit this form to demonstrate entitlement to Medicare benefits. |
| Required Information | Applicants must provide personal details, including their Social Security number, date of birth, and information regarding current health coverage. |
| Filing Process | The completed form should be submitted directly to the Social Security Administration to initiate the Medicare enrollment process. |
| Where to Obtain | This form can be downloaded from the official CMS website or obtained at local Social Security offices. |
| State-Specific Laws | Different states may have specific laws governing the use of the CMS L564/R297 form. Check state health regulations for details. |
| Submission Timing | It is recommended to submit the form at least three months before turning 65 to avoid gaps in coverage. |
| Review Process | The submitted form will undergo a review process by the Social Security Administration to determine eligibility for benefits. |
| Contact Information | For questions regarding the CMS L564/R297 form, individuals may contact the Social Security Administration or visit their official website for assistance. |
Guide to Using CMS L564/R297
Once you have gathered the necessary information, completing the CMS L564/R297 form is crucial for your next steps. This process involves providing accurate details to ensure that your request is processed promptly. Follow the steps below carefully to fill out the form correctly.
- Begin by downloading the CMS L564/R297 form from the official Medicare website or an authorized source.
- Enter your personal information in the designated sections, including your full name, address, and date of birth.
- Provide your Medicare number, if you have one, in the appropriate field.
- Complete the information about the individual you are assisting, if applicable, by filling in their name and relevant data.
- Detail the situation that led you to fill out this form, specifying any relevant dates and circumstances.
- Carefully review your entries for accuracy. A mistake could delay the process.
- Sign and date the form at the bottom to validate your submission.
- Make a copy of the completed form for your records before sending it.
- Submit the form by mailing it to the address provided in the instructions or as specified by your local Medicare office.
Get Answers on CMS L564/R297
What is the CMS L564/R297 form used for?
The CMS L564/R297 form is primarily used by individuals seeking to enroll in Medicare. This form assists individuals in verifying their prior health coverage and determining their eligibility for Medicare benefits. It can be particularly useful for those transitioning from employer-sponsored health plans, as it helps demonstrate their creditable coverage, which can affect their enrollment periods and benefit costs.
Who needs to fill out the CMS L564/R297 form?
Individuals who are eligible for Medicare and have had prior health insurance coverage typically need to complete this form. This includes those who are approaching age 65, individuals with disabilities, and those who may qualify due to certain medical conditions. Additionally, if you’ve recently lost health coverage or are looking to switch to Medicare from another provider, this form is relevant.
How do I obtain the CMS L564/R297 form?
You can obtain the CMS L564/R297 form directly from the Centers for Medicare & Medicaid Services (CMS) website. The form is available for download in PDF format, making it easy to fill out. Some healthcare providers or Medicare offices may also have physical copies available; however, obtaining it online is often the quickest method.
What information do I need to provide on the form?
The CMS L564/R297 form requires specific details to verify your prior insurance coverage. Key information includes:
- Your personal information (name, address, date of birth)
- The name and contact information of your previous insurance plan
- Start and end dates of your coverage
- Types of coverage received (e.g., employer-sponsored, individual policy)
Ensure that all data is accurate, as this will affect your enrollment process.
Where do I send the completed CMS L564/R297 form?
Once you have completed the CMS L564/R297 form, you can submit it to the Social Security Administration (SSA) along with your Medicare enrollment application. The SSA accepts submissions via mail, and in some cases, you may be able to deliver it in person at your local SSA office. It’s essential to check the current submission options, as policies may change.
What happens after I submit the CMS L564/R297 form?
After submitting the completed form, the SSA will review your information to confirm your eligibility for Medicare benefits. You will receive a notification regarding your enrollment status typically within a few weeks. If there are any issues with your submission, the SSA will contact you for further information. To avoid delays, ensure that all information is complete and accurate when you submit the form.
Common mistakes
When it comes to completing the CMS L564/R297 form, several common pitfalls can arise. These mistakes can lead to delays in processing and potential issues with eligibility for benefits. Here, we'll explore eight frequent errors individuals make when filling out this important document.
One of the first mistakes is providing incomplete information. Each section of the form is designed to gather specific details. Omitting any required information can lead to a rejection of the application. Ensuring that every box is filled out accurately and completely is essential for smoother processing.
Another common error is confusing the dates. People often misinterpret the date fields, particularly the start and end dates of coverage. This error can misconstrue the timeline of eligibility, impacting access to necessary services. Double-checking dates before submission can save a lot of headaches.
Many individuals fail to sign the form. A signature is not just a formality; it serves as an acknowledgment of the information provided. Without a valid signature, the form is considered incomplete and invalid. Always remember to sign and date your submission.
It is also crucial to ensure that the contact information provided is correct. If there are any changes to your phone number, email, or address, these should be updated on the form. Incorrect contact details can lead to missed communications from the CMS, which can cause unnecessary delays.
Another key error involves not providing supporting documents. If the form prompts for additional attachments—like proof of prior health coverage—failing to include these can result in a rejection. This can be frustrating, as it delays the entire process and requires resubmission.
Overlooking the submission deadline is a mistake too. Each form has a specific timeline for submission based on when you apply for a benefit. Missing this deadline can disqualify an applicant from receiving assistance. Marking important dates on your calendar can help keep everything on track.
Sometimes, applicants do not keep a copy of their submitted form. This can be problematic should questions arise later on or if there is a discrepancy in the information. Retaining a copy of all submitted documents ensures individuals have a record to refer back to when needed.
Lastly, failing to consult for help when needed can be detrimental. Many resources, including helplines and community organizations, are available to assist with the form. Seeking help from these resources can clarify doubts and guide towards accurate completion of the form.
Documents used along the form
The CMS L564/R297 form is commonly used in health insurance contexts, particularly for individuals transitioning to Medicare. Along with this form, several other documents may be required or helpful during the application or enrollment process. Below is a list of related forms and documents that may be used in conjunction with the CMS L564/R297 form.
- CMS 40B Form: This form is used to apply for Medicare Part B. It is essential for those who want to enroll in Medicare and need to provide personal information for coverage.
- Medicare Card: A Medicare card is issued to eligible individuals. It serves as proof of Medicare coverage and includes essential details like a person's Medicare number.
- CMS 1510 Form: This is often used to submit a claim to Medicare for covered services. Providers often require this form to ensure proper billing procedures.
- Social Security Number Card: The Social Security number is crucial for various health insurance forms, including applications for Medicare. It helps to verify identity and eligibility.
- Proof of Employment: Documentation such as pay stubs or a letter from an employer may be necessary. This proof can be important for determining eligibility for certain Medicare options.
Having these documents on hand can streamline the process and help ensure that individuals receive the benefits to which they are entitled. Each of these forms serves a distinct purpose and may be important depending on individual circumstances related to healthcare coverage and enrollment.
Similar forms
Form CMS-40B: This form is used for enrolling in Medicare Part B. Similar to the L564/R297, it establishes eligibility for benefits and requires information on previous health coverage, ensuring a smooth transition into Medicare services.
Form CMS-10106: This is the Application for Medicare Savings Program. Like the L564/R297, it helps determine eligibility for specific Medicare-related programs, assisting individuals in navigating their healthcare options.
Form CMS-15426: The CMS-15426 is the request for a refund of premium overpayment. This document also involves collecting information about previous coverage and can help facilitate financial transactions related to Medicare.
Form SSA-827: This form authorizes the release of medical information for Medicare or Social Security benefits. Its purpose aligns with the L564/R297 in that it ensures the required medical data is accessible for eligibility determinations.
Form SSA-3881: This is the Request for Earning Statements. Similar to the L564/R297, it verifies work history and earnings, which can impact Medicare benefits and eligibility, particularly for those nearing retirement.
Form CMS-179: The CMS-179 is a request for a waiver of certain Medicare conditions. It directly addresses eligibility requirements and seeks to provide exceptions, similar to how the L564/R297 helps individuals qualify for Medicare based on their existing coverage.
Dos and Don'ts
Filling out the CMS L564/R297 form can be a vital step in ensuring proper healthcare coverage. Here is a list of important do's and don'ts to keep in mind while completing the form:
- Do read the instructions carefully before beginning the form.
- Don’t leave any required fields blank; incomplete information may delay processing.
- Do provide accurate and up-to-date information regarding your situation.
- Don’t use abbreviations that might confuse the reviewer.
- Do double-check all numbers and dates for accuracy.
- Don’t submit any additional documentation unless specifically requested.
- Do keep a copy of the completed form for your records.
- Don’t assume the form is processed immediately; allow time for processing after submission.
- Do reach out to customer service if you have questions or need clarification.
By following these guidelines, you can ensure a smoother experience in navigating the complexities of this form.
Misconceptions
The CMS L564/R297 form, used mainly in the context of Medicare enrollment, often faces various misconceptions. Here is a clearer understanding of some common misunderstandings surrounding this form:
- Misconception 1: The form is only for people aged 65 and older.
- Misconception 2: Submitting the form guarantees immediate coverage.
- Misconception 3: The form can be submitted at any time.
- Misconception 4: The form is only necessary if you are switching plans.
- Misconception 5: You can't use the form if you have private insurance.
- Misconception 6: The CMS L564/R297 form is the same as other CMS forms.
- Misconception 7: You can fill it out incorrectly without consequences.
- Misconception 8: The form must be submitted in person.
- Misconception 9: Completing this form is a one-time event.
Many believe the form applies exclusively to seniors. However, it is also relevant for younger individuals eligible for Medicare due to certain disabilities.
Some individuals think that filling out the form leads to instant Medicare coverage. In reality, coverage begins only after the enrollment process is complete and approved.
People often assume there are no deadlines. However, there are specific enrollment periods when the form must be submitted to avoid penalties and gaps in coverage.
Some believe it is required only when changing from one plan to another. Yet, it is critical for initial enrollment in Medicare as well.
Many think that private insurance disqualifies them from using the form. However, those with private insurance may still need to submit this form to enroll in Medicare.
People often confuse this form with others like the CMS 40B. Each form serves distinct purposes related to Medicare and has different requirements.
Some individuals believe errors on the form don't matter. However, inaccuracies can delay processing and impact eligibility.
There is a common belief that personal submission is necessary. This is not true; you can mail the form or submit it online in many cases.
People often think they only need to fill it out once. Depending on life events such as moving or changes in health status, you may need to resubmit or update your information periodically.
Key takeaways
The CMS L564/R297 form is an important document for those seeking to enroll in Medicare. Understanding how to properly fill out and use this form can help ensure a smoother process. Here are some key takeaways regarding its use:
- Purpose of the Form: The CMS L564/R297 is primarily used to provide proof of prior health coverage or employment when applying for Medicare.
- Eligibility: Individuals who are nearing 65 or those who qualify due to disability may need to complete this form to enroll in Medicare.
- Information Required: The form requires details such as personal information, type of prior coverage, and dates of coverage.
- Timing: It is crucial to submit the form during the appropriate enrollment period to avoid delays and potential penalties.
- Multiple Uses: The form can also serve as evidence of coverage for various situations, not limited to Medicare but also for other health-related benefits.
- Signature Requirement: Ensure that all required sections are completed, and the form is signed. An unsigned form may not be accepted.
- Submission Methods: The form can be submitted via mail or electronically, depending on the specific instructions provided by CMS.
- Record Keeping: Retain a copy of the completed form for your records, as it may be needed in the future for verification purposes.
- Seek Assistance if Needed: Consider seeking help from healthcare professionals or counselors if you encounter difficulties completing the form.
By keeping these points in mind, individuals can better navigate the process of completing and submitting the CMS L564/R297 form for Medicare enrollment.