---
title: CMS-L564 Customer-Assembly Preparation Kit
description: Prepare Section A of CMS-L564 online and receive the printed form for employer completion, final assembly, and submission.
seotitle: CMS-L564 Customer-Assembly Preparation Kit
seo-description: Prepare Section A of CMS-L564 online and receive the printed form for employer completion, final assembly, and submission.
group: resources
indexable: true
llms: false
schema: webpage
og-image: /forms/cms-l564/thumbnail
og-image-alt: Form CMS-L564 - Medicare Employment Verification generated form preview
published: 2026-07-12
updated: 2026-07-12
tags:
  - medicare
  - medicare part b
  - social security
path: /forms/cms-l564
---
# CMS-L564 Customer-Assembly Preparation Kit

Prepare Section A of CMS-L564 online and receive the printed form for employer completion, final assembly, and submission.

## 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.** -


## 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.

## 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

## Data collected
- Applicant name and Social Security number
- Covered worker's name (and SSN, if known) when coverage is through a spouse or family member
- Employer name and address needed in applicant-controlled Section A

## Where it gets mailed
PostalForm mails the unsigned preparation kit only to the customer or authorized signer at the verified delivery address entered during checkout.

Final submission: 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.

## 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.

## Agent summary
Customer-assembly workflow for CMS-L564. It prepares applicant-controlled Section A only and sends the kit only to the customer; employer Section B remains blank. It must never be represented as direct filing or agency submission. Final action: have an authorized employer official complete and sign Section B, then combine it with the applicable enrollment form and submit it yourself.

## For assistants
This is a human-only customer-assembly workflow and is not available for automated or machine ordering.

- PostalForm delivers an unsigned preparation kit only to the customer or authorized signer.
- The customer must remove and keep the PostalForm cover, complete every physical signature, enclosure, certification, and final-submission step, and verify the current deadline and destination.

## LLM field schema
```json
[
  {
    "id": "section_b_plan",
    "label": "Who will fill out Section B (the employer part)?",
    "type": "select",
    "required": false,
    "meta_class": null,
    "ui_width": null,
    "group_id": "basics",
    "choice_group": null,
    "choice_label": null,
    "visibility": null,
    "compound_subfields": null
  },
  {
    "id": "applicant_name",
    "label": "Your full name",
    "type": "text",
    "required": true,
    "meta_class": "name",
    "ui_width": "half",
    "group_id": "about-you",
    "choice_group": null,
    "choice_label": null,
    "visibility": null,
    "compound_subfields": null
  },
  {
    "id": "applicant_ssn_part1",
    "label": "Social Security number - first 3 digits",
    "type": "text",
    "required": true,
    "meta_class": "number",
    "ui_width": "third",
    "group_id": "about-you",
    "choice_group": null,
    "choice_label": null,
    "visibility": null,
    "compound_subfields": null
  },
  {
    "id": "applicant_ssn_part2",
    "label": "Middle 2 digits",
    "type": "text",
    "required": true,
    "meta_class": "number",
    "ui_width": "third",
    "group_id": "about-you",
    "choice_group": null,
    "choice_label": null,
    "visibility": null,
    "compound_subfields": null
  },
  {
    "id": "applicant_ssn_part3",
    "label": "Last 4 digits",
    "type": "text",
    "required": true,
    "meta_class": "number",
    "ui_width": "third",
    "group_id": "about-you",
    "choice_group": null,
    "choice_label": null,
    "visibility": null,
    "compound_subfields": null
  },
  {
    "id": "worker_is_other",
    "label": "Does the health coverage come from someone else's job - like your husband, wife, or another family member?",
    "type": "checkbox",
    "required": true,
    "meta_class": "yes_no",
    "ui_width": null,
    "group_id": "about-you",
    "choice_group": null,
    "choice_label": null,
    "visibility": null,
    "compound_subfields": null
  },
  {
    "id": "employee_name",
    "label": "Worker's full name",
    "type": "text",
    "required": true,
    "meta_class": "name",
    "ui_width": "half",
    "group_id": "about-you",
    "choice_group": null,
    "choice_label": null,
    "visibility": {
      "fieldId": "worker_is_other",
      "operator": "truthy"
    },
    "compound_subfields": null
  },
  {
    "id": "employee_ssn_part1",
    "label": "Worker's SSN - first 3 digits",
    "type": "text",
    "required": false,
    "meta_class": "number",
    "ui_width": "third",
    "group_id": "about-you",
    "choice_group": null,
    "choice_label": null,
    "visibility": {
      "fieldId": "worker_is_other",
      "operator": "truthy"
    },
    "compound_subfields": null
  },
  {
    "id": "employee_ssn_part2",
    "label": "Middle 2 digits",
    "type": "text",
    "required": false,
    "meta_class": "number",
    "ui_width": "third",
    "group_id": "about-you",
    "choice_group": null,
    "choice_label": null,
    "visibility": {
      "fieldId": "worker_is_other",
      "operator": "truthy"
    },
    "compound_subfields": null
  },
  {
    "id": "employee_ssn_part3",
    "label": "Last 4 digits",
    "type": "text",
    "required": false,
    "meta_class": "number",
    "ui_width": "third",
    "group_id": "about-you",
    "choice_group": null,
    "choice_label": null,
    "visibility": {
      "fieldId": "worker_is_other",
      "operator": "truthy"
    },
    "compound_subfields": null
  },
  {
    "id": "employer_name",
    "label": "Employer's name",
    "type": "text",
    "required": true,
    "meta_class": "business_name",
    "ui_width": null,
    "group_id": "employer",
    "choice_group": null,
    "choice_label": null,
    "visibility": null,
    "compound_subfields": null
  },
  {
    "id": "employer_address_street",
    "label": "Employer's mailing address (number and street)",
    "type": "text",
    "required": true,
    "meta_class": "address",
    "ui_width": "full",
    "group_id": "employer",
    "choice_group": null,
    "choice_label": null,
    "visibility": null,
    "compound_subfields": null
  },
  {
    "id": "employer_city",
    "label": "City",
    "type": "text",
    "required": true,
    "meta_class": "city",
    "ui_width": "third",
    "group_id": "employer",
    "choice_group": null,
    "choice_label": null,
    "visibility": null,
    "compound_subfields": null
  },
  {
    "id": "employer_state",
    "label": "State",
    "type": "text",
    "required": true,
    "meta_class": "state",
    "ui_width": "third",
    "group_id": "employer",
    "choice_group": null,
    "choice_label": null,
    "visibility": null,
    "compound_subfields": null
  },
  {
    "id": "employer_zip",
    "label": "ZIP code",
    "type": "text",
    "required": true,
    "meta_class": "zip",
    "ui_width": "third",
    "group_id": "employer",
    "choice_group": null,
    "choice_label": null,
    "visibility": null,
    "compound_subfields": null
  },
  {
    "id": "ghp_covered_yes",
    "label": "Yes",
    "type": "checkbox",
    "required": false,
    "meta_class": "radio",
    "ui_width": null,
    "group_id": "section-b",
    "choice_group": null,
    "choice_label": null,
    "visibility": null,
    "compound_subfields": null
  },
  {
    "id": "ghp_covered_no",
    "label": "No",
    "type": "checkbox",
    "required": false,
    "meta_class": "radio",
    "ui_width": null,
    "group_id": "section-b",
    "choice_group": null,
    "choice_label": null,
    "visibility": null,
    "compound_subfields": null
  },
  {
    "id": "ghp_start_month",
    "label": "Month the applicant's coverage started",
    "type": "text",
    "required": false,
    "meta_class": "date",
    "ui_width": "quarter",
    "group_id": "section-b",
    "choice_group": null,
    "choice_label": null,
    "visibility": {
      "fieldId": "ghp_covered_yes",
      "operator": "truthy"
    },
    "compound_subfields": null
  },
  {
    "id": "ghp_start_year",
    "label": "Year the applicant's coverage started",
    "type": "text",
    "required": false,
    "meta_class": "date",
    "ui_width": "quarter",
    "group_id": "section-b",
    "choice_group": null,
    "choice_label": null,
    "visibility": {
      "fieldId": "ghp_covered_yes",
      "operator": "truthy"
    },
    "compound_subfields": null
  },
  {
    "id": "coverage_ended_yes",
    "label": "Yes - it has ended",
    "type": "checkbox",
    "required": false,
    "meta_class": "radio",
    "ui_width": null,
    "group_id": "section-b",
    "choice_group": null,
    "choice_label": null,
    "visibility": {
      "fieldId": "ghp_covered_yes",
      "operator": "truthy"
    },
    "compound_subfields": null
  },
  {
    "id": "coverage_ended_no",
    "label": "No - it is still active",
    "type": "checkbox",
    "required": false,
    "meta_class": "radio",
    "ui_width": null,
    "group_id": "section-b",
    "choice_group": null,
    "choice_label": null,
    "visibility": {
      "fieldId": "ghp_covered_yes",
      "operator": "truthy"
    },
    "compound_subfields": null
  },
  {
    "id": "ghp_end_month",
    "label": "Month the coverage ended",
    "type": "text",
    "required": false,
    "meta_class": "date",
    "ui_width": "quarter",
    "group_id": "section-b",
    "choice_group": null,
    "choice_label": null,
    "visibility": {
      "fieldId": "coverage_ended_yes",
      "operator": "truthy"
    },
    "compound_subfields": null
  },
  {
    "id": "ghp_end_year",
    "label": "Year the coverage ended",
    "type": "text",
    "required": false,
    "meta_class": "date",
    "ui_width": "quarter",
    "group_id": "section-b",
    "choice_group": null,
    "choice_label": null,
    "visibility": {
      "fieldId": "coverage_ended_yes",
      "operator": "truthy"
    },
    "compound_subfields": null
  },
  {
    "id": "employment_start_month",
    "label": "Month the employee started working there",
    "type": "text",
    "required": false,
    "meta_class": "date",
    "ui_width": "quarter",
    "group_id": "section-b",
    "choice_group": null,
    "choice_label": null,
    "visibility": {
      "fieldId": "ghp_covered_yes",
      "operator": "truthy"
    },
    "compound_subfields": null
  },
  {
    "id": "employment_start_year",
    "label": "Year the employee started working there",
    "type": "text",
    "required": false,
    "meta_class": "date",
    "ui_width": "quarter",
    "group_id": "section-b",
    "choice_group": null,
    "choice_label": null,
    "visibility": {
      "fieldId": "ghp_covered_yes",
      "operator": "truthy"
    },
    "compound_subfields": null
  },
  {
    "id": "still_employed_yes",
    "label": "Yes - still employed",
    "type": "checkbox",
    "required": false,
    "meta_class": "radio",
    "ui_width": null,
    "group_id": "section-b",
    "choice_group": null,
    "choice_label": null,
    "visibility": {
      "fieldId": "ghp_covered_yes",
      "operator": "truthy"
    },
    "compound_subfields": null
  },
  {
    "id": "still_employed_no",
    "label": "No - the employment ended",
    "type": "checkbox",
    "required": false,
    "meta_class": "radio",
    "ui_width": null,
    "group_id": "section-b",
    "choice_group": null,
    "choice_label": null,
    "visibility": {
      "fieldId": "ghp_covered_yes",
      "operator": "truthy"
    },
    "compound_subfields": null
  },
  {
    "id": "employment_end_month",
    "label": "Month the employment ended",
    "type": "text",
    "required": false,
    "meta_class": "date",
    "ui_width": "quarter",
    "group_id": "section-b",
    "choice_group": null,
    "choice_label": null,
    "visibility": {
      "fieldId": "still_employed_no",
      "operator": "truthy"
    },
    "compound_subfields": null
  },
  {
    "id": "employment_end_year",
    "label": "Year the employment ended",
    "type": "text",
    "required": false,
    "meta_class": "date",
    "ui_width": "quarter",
    "group_id": "section-b",
    "choice_group": null,
    "choice_label": null,
    "visibility": {
      "fieldId": "still_employed_no",
      "operator": "truthy"
    },
    "compound_subfields": null
  },
  {
    "id": "applicant_disabled",
    "label": "Does the applicant qualify for Medicare because of a disability?",
    "type": "checkbox",
    "required": false,
    "meta_class": "yes_no",
    "ui_width": null,
    "group_id": "section-b",
    "choice_group": null,
    "choice_label": null,
    "visibility": null,
    "compound_subfields": null
  },
  {
    "id": "disability_primary_start_month",
    "label": "Month the plan became primary payer",
    "type": "text",
    "required": false,
    "meta_class": "date",
    "ui_width": "quarter",
    "group_id": "section-b",
    "choice_group": null,
    "choice_label": null,
    "visibility": {
      "fieldId": "applicant_disabled",
      "operator": "truthy"
    },
    "compound_subfields": null
  },
  {
    "id": "disability_primary_start_year",
    "label": "Year the plan became primary payer",
    "type": "text",
    "required": false,
    "meta_class": "date",
    "ui_width": "quarter",
    "group_id": "section-b",
    "choice_group": null,
    "choice_label": null,
    "visibility": {
      "fieldId": "applicant_disabled",
      "operator": "truthy"
    },
    "compound_subfields": null
  },
  {
    "id": "disability_primary_end_month",
    "label": "Month the plan stopped being primary",
    "type": "text",
    "required": false,
    "meta_class": "date",
    "ui_width": "quarter",
    "group_id": "section-b",
    "choice_group": null,
    "choice_label": null,
    "visibility": {
      "fieldId": "applicant_disabled",
      "operator": "truthy"
    },
    "compound_subfields": null
  },
  {
    "id": "disability_primary_end_year",
    "label": "Year the plan stopped being primary",
    "type": "text",
    "required": false,
    "meta_class": "date",
    "ui_width": "quarter",
    "group_id": "section-b",
    "choice_group": null,
    "choice_label": null,
    "visibility": {
      "fieldId": "applicant_disabled",
      "operator": "truthy"
    },
    "compound_subfields": null
  },
  {
    "id": "hours_bank_yes",
    "label": "Yes",
    "type": "checkbox",
    "required": false,
    "meta_class": "radio",
    "ui_width": null,
    "group_id": "section-b",
    "choice_group": null,
    "choice_label": null,
    "visibility": null,
    "compound_subfields": null
  },
  {
    "id": "hours_bank_no",
    "label": "No",
    "type": "checkbox",
    "required": false,
    "meta_class": "radio",
    "ui_width": null,
    "group_id": "section-b",
    "choice_group": null,
    "choice_label": null,
    "visibility": null,
    "compound_subfields": null
  },
  {
    "id": "reserve_hours_yes",
    "label": "Yes",
    "type": "checkbox",
    "required": false,
    "meta_class": "radio",
    "ui_width": null,
    "group_id": "section-b",
    "choice_group": null,
    "choice_label": null,
    "visibility": {
      "fieldId": "hours_bank_yes",
      "operator": "truthy"
    },
    "compound_subfields": null
  },
  {
    "id": "reserve_hours_no",
    "label": "No",
    "type": "checkbox",
    "required": false,
    "meta_class": "radio",
    "ui_width": null,
    "group_id": "section-b",
    "choice_group": null,
    "choice_label": null,
    "visibility": {
      "fieldId": "hours_bank_yes",
      "operator": "truthy"
    },
    "compound_subfields": null
  },
  {
    "id": "reserve_end_month",
    "label": "Month the reserve hours ended or will run out",
    "type": "text",
    "required": false,
    "meta_class": "date",
    "ui_width": "quarter",
    "group_id": "section-b",
    "choice_group": null,
    "choice_label": null,
    "visibility": {
      "fieldId": "reserve_hours_yes",
      "operator": "truthy"
    },
    "compound_subfields": null
  },
  {
    "id": "reserve_end_year",
    "label": "Year the reserve hours ended or will run out",
    "type": "text",
    "required": false,
    "meta_class": "date",
    "ui_width": "quarter",
    "group_id": "section-b",
    "choice_group": null,
    "choice_label": null,
    "visibility": {
      "fieldId": "reserve_hours_yes",
      "operator": "truthy"
    },
    "compound_subfields": null
  },
  {
    "id": "official_title",
    "label": "Title of the company official who will sign",
    "type": "text",
    "required": false,
    "meta_class": null,
    "ui_width": "half",
    "group_id": "section-b",
    "choice_group": null,
    "choice_label": null,
    "visibility": null,
    "compound_subfields": null
  },
  {
    "id": "official_phone_area",
    "label": "Official's phone - area code",
    "type": "text",
    "required": false,
    "meta_class": "number",
    "ui_width": "quarter",
    "group_id": "section-b",
    "choice_group": null,
    "choice_label": null,
    "visibility": null,
    "compound_subfields": null
  },
  {
    "id": "official_phone_prefix",
    "label": "Phone - next 3 digits",
    "type": "text",
    "required": false,
    "meta_class": "number",
    "ui_width": "quarter",
    "group_id": "section-b",
    "choice_group": null,
    "choice_label": null,
    "visibility": null,
    "compound_subfields": null
  },
  {
    "id": "official_phone_line",
    "label": "Phone - last 4 digits",
    "type": "text",
    "required": false,
    "meta_class": "number",
    "ui_width": "quarter",
    "group_id": "section-b",
    "choice_group": null,
    "choice_label": null,
    "visibility": null,
    "compound_subfields": null
  },
  {
    "id": "official_signature",
    "label": "Company official's signature",
    "type": "signature",
    "required": false,
    "meta_class": null,
    "ui_width": null,
    "group_id": "section-b",
    "choice_group": null,
    "choice_label": null,
    "visibility": {
      "fieldId": "section_b_plan",
      "operator": "equals",
      "value": "I am an owner or officer of the company - I'll complete and sign Section B myself"
    },
    "compound_subfields": null
  },
  {
    "id": "official_date_signed_month",
    "label": "Date signed",
    "type": "text",
    "required": false,
    "meta_class": "date",
    "ui_width": null,
    "group_id": "section-b",
    "choice_group": null,
    "choice_label": null,
    "visibility": {
      "fieldId": "section_b_plan",
      "operator": "equals",
      "value": "I am an owner or officer of the company - I'll complete and sign Section B myself"
    },
    "compound_subfields": null
  },
  {
    "id": "official_date_signed_day",
    "label": "Day",
    "type": "text",
    "required": false,
    "meta_class": "date",
    "ui_width": null,
    "group_id": "section-b",
    "choice_group": null,
    "choice_label": null,
    "visibility": {
      "fieldId": "section_b_plan",
      "operator": "equals",
      "value": "I am an owner or officer of the company - I'll complete and sign Section B myself"
    },
    "compound_subfields": null
  },
  {
    "id": "official_date_signed_year",
    "label": "Year",
    "type": "text",
    "required": false,
    "meta_class": "date",
    "ui_width": null,
    "group_id": "section-b",
    "choice_group": null,
    "choice_label": null,
    "visibility": {
      "fieldId": "section_b_plan",
      "operator": "equals",
      "value": "I am an owner or officer of the company - I'll complete and sign Section B myself"
    },
    "compound_subfields": null
  },
  {
    "id": "mail_to_employer_ack",
    "label": "I'll send this to my employer's benefits office to finish Section B",
    "type": "checkbox",
    "required": false,
    "meta_class": "plain_checkbox",
    "ui_width": null,
    "group_id": "mailing",
    "choice_group": null,
    "choice_label": null,
    "visibility": {
      "fieldId": "section_b_plan",
      "operator": "in",
      "value": [
        "My employer will complete Section B - mail them the form with that part left blank (most common)",
        "I already have the employer's answers - fill Section B in; the company official will sign it"
      ]
    },
    "compound_subfields": null
  },
  {
    "id": "mail_to_ssa_ack",
    "label": "I'll mail this with my Part B application to my local Social Security office",
    "type": "checkbox",
    "required": false,
    "meta_class": "plain_checkbox",
    "ui_width": null,
    "group_id": "mailing",
    "choice_group": null,
    "choice_label": null,
    "visibility": {
      "fieldId": "section_b_plan",
      "operator": "equals",
      "value": "I am an owner or officer of the company - I'll complete and sign Section B myself"
    },
    "compound_subfields": null
  }
]
```

## Sources
- [CMS - CMS-L564 Request for Employment Information overview](https://www.cms.gov/cms-l564-request-employment-information)
- [SSA - Sign up for Part B only](https://www.ssa.gov/medicare/sign-up/part-b-only)
- [Medicare.gov - Ready to sign up for Part A and Part B](https://www.medicare.gov/basics/get-started-with-medicare/sign-up/ready-to-sign-up-for-part-a-part-b)
- [Official instructions](https://www.cms.gov/medicare/cms-forms/cms-forms/cms-forms-items/cms009718)
- [Official PDF](https://www.cms.gov/medicare/cms-forms/cms-forms/downloads/cms-l564e.pdf)

## Last verified
2026-07-12


## 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.


## Related
- [Form CMS-40B - Medicare Part B Enrollment](/forms/cms-40b)
- [Form CMS-1763 — Medicare Part A/B Termination Request](/forms/cms-1763)
- [CMS-1490S](/forms/cms-1490s)
- [Form SSA-44 — Medicare IRMAA Reduction Request (Life-Changing Event)](/forms/ssa-44)
- [Form SS-5 — Application for a Social Security Card](/forms/ss-5)
- [SSA-1696 — Appointment of Representative (Social Security)](/forms/ssa-1696)