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Step 1 of 2Centers for Medicare & Medicaid Services · CMS-L564 · 03/2025

CMS-L564 Customer-Assembly Preparation Kit

This workflow helps you prepare only the applicant-controlled Section A of Medicare employment verification. PostalForm delivers the preparation kit only to your verified address and does not file or submit it. Give the form to the employer, have an authorized company official complete and hand-sign Section B, then combine it with CMS-40B or the applicable enrollment form and submit the final package to Social Security yourself.

Prepare CMS-L564 for your own final assembly and submission

PostalForm prepares and prints an unsigned customer-assembly kit and sends it only to your verified address. You perform final assembly and submission.

Preparation and delivery record only — not proof of filing or agency receipt
Current step
Section A - about you
Your full name, Social Security number - first 3 digits, and Middle 2 digits
This step
5 fields · 5 required

PostalForm is not affiliated with Centers for Medicare & Medicaid Services.

Step 1

Section A - about you

Your full name, Social Security number - first 3 digits, and Middle 2 digits

5 required

You are the "applicant" - the person signing up for Medicare Part B.

Your SSN, split into the three boxes printed on the form.

Does the health coverage come from someone else's job - like your husband, wife, or another family member? *

Answer Yes if the group health plan belongs to your spouse's or a family member's employment instead of your own. We'll add that worker's name so the employer can find the right records.

Need more context?

The form is ready to fill now. If you want supporting instructions, mailing notes, or source links, they are below.

Important details+

Answer the guided questions and PostalForm prepares the official form, leaves signature areas blank, adds a customer instruction cover, and sends the packet only to your verified address. Nothing is filed or submitted for you. Give the printed form to the employer, have an authorized company official verify Section B and hand-sign and date it, then combine it with CMS-40B or the applicable enrollment form and submit the final package to Social Security yourself.

What you need+
  • Applicant's name and Social Security number
  • The covered worker's name, if the coverage came through a spouse or family member
  • Employer's name and mailing address (HR or benefits office if known)
  • Access to an authorized employer official who will complete and sign Section B after delivery
  • Form CMS-40B to submit alongside this form
  • Hand-sign the printed form after the preparation kit is delivered
Form summary+

This workflow helps you prepare only the applicant-controlled Section A of Medicare employment verification. PostalForm delivers the preparation kit only to your verified address and does not file or submit it. Give the form to the employer, have an authorized company official complete and hand-sign Section B, then combine it with CMS-40B or the applicable enrollment form and submit the final package to Social Security yourself.

How it works+
  1. Answer the guided questions and review the prepared form information.
  2. PostalForm prints the official form with signature areas left blank and sends the customer-assembly kit only to your verified address.
  3. After delivery, give the form to an authorized employer official to complete and hand-sign Section B.
  4. Verify the current deadline and destination, then personally complete final submission through the official channel.
Where it gets mailed+

PostalForm mails the unsigned preparation kit to you. You complete the signatures, physical enclosures, and final submission yourself.

Packet order+
  • Customer assembly instruction cover (remove and keep before final submission)
  • Prepared unsigned form (signature and reserved third-party fields blank)
Common mistakes+
  • Filling in Section B yourself when it must be completed and signed by the employer.
  • Mailing CMS-L564 to Social Security before the employer has completed and signed Section B.
  • Sending the finished package to a national Medicare address - it goes to your local Social Security office.
  • Forgetting a separate verification for each employer whose coverage you are counting since you turned 65.
  • Giving up when an employer cannot complete it - Social Security accepts other proof like W-2s, pay stubs, health insurance cards, and benefit statements.
FAQs+
Who fills out Form CMS-L564?

You (the applicant) complete Section A. Your employer - usually HR or the benefits office - completes and signs Section B. If you own the company, you can complete both parts yourself.

Where do I send Form CMS-L564?

First to the employer so they can complete Section B. Once it is signed, submit it with Form CMS-40B to your local Social Security office by mail or fax (1-833-914-2016). There is no national mailing address - find your office at secure.ssa.gov/ICON.

What if my employer went out of business or will not complete Section B?

Social Security accepts other proof of group health plan coverage: W-2s reflecting pre-tax medical contributions, pay stubs showing premium deductions, tax returns showing premiums paid, health insurance cards with effective dates, or explanations of benefits.

Do I need a separate CMS-L564 for each employer?

If you are counting coverage from more than one employer since you turned 65, each employer’s coverage should be verified - a separate CMS-L564 (or equivalent proof) for each.

Do I need this form at all?

Only for a Special Enrollment Period based on job coverage. If you are enrolling during your Initial Enrollment Period or the January-March General Enrollment Period, Form CMS-40B alone is enough. And if you apply online at ssa.gov/medicare/sign-up, you upload proof instead of mailing this form.

Does COBRA or retiree coverage count?

No - the Special Enrollment Period requires coverage based on current employment. Your 8-month window starts when the employment or the active-employment coverage ends, whichever comes first.

Sources+
Related+
Last verified+

Last Centers for Medicare & Medicaid Services verification: July 12, 2026