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12 Dec 2019 - The Social Security Administration's (SSA) form CMS-L564 is an employment verification form. The purpose of this form is to apply for a Special Enrollment Form CMS-L564 (04/10) collection is estimated to average 15 minutes per response, including the time to review instructions, search existing data resources, Video instructions and help with filling out and completing cms l564. Instructions and Help about l564 form. Hello and welcome to the Medicare and Federal 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 (CMS-40B). Then you send both together to your local Social Security office. Form CMS-L564 ”Request for Employment Information” completed by 0938-1230. STEP BY STEP INSTRUCTIONS FOR FILLING OUT THIS APPLICATION. 1. CMS 40B (Application for Enrollment in Medicare). CMS L564 (Request for Employment Information). Fill out and sign form CMS 40B and have your employerFill out the Patient Request for Medical Payment form (CMS-1490S).You'll find the address for form submission in the instructions. has ended, and I need to provide employment information (Request for Employment Information/CMS-L564). CMS L564. Form #. CMS L564. Form Title. REQUEST FOR EMPLOYMENT INFORMATION. Revision Date Special Instructions. Return the completed form to CMS L564. Form #. CMS L564. Form Title. REQUEST FOR EMPLOYMENT INFORMATION. Revision Date Special Instructions. Return the completed form to