Request a completed CMS L-564: Medicare Request for Employment Information

Get a completed CMS L-564

1. You submit a request to OPM

   Complete the contact form below.
   

   • For "Topic", select Health Benefits.
   • In the description section, tell us that you would like a completed CMS L-564, and tell us if you would like the form to be returned via email or mail. If you are requesting one for your spouse, please call us at 1-888-767-6738 (TTY: 711) Monday thru Friday, 7:40 a.m. to 5:00 p.m. ET. We are closed on federal holidays. 

2. OPM verifies your eligibility and returns your completed form

   Once you submit your information, OPM verifies your eligibility. If you are eligible, OPM will complete the form and return it to you by email or mail, depending on how you requested to receive the form.

3. You submit the form to the Social Security Administration

   Submit the completed form, along with your Request for Enrollment in Medicare Part B (Medical Insurance) (CMS-40B), to your local Social Security office by mail or fax. You can find SSA office locations at SSA.gov/locator. Contact Social Security at 1-800-772-1213 (TTY 1-800-325-0778) with questions.

Note: To enroll in Medicare through a Special Enrollment Period, you must have had group health plan coverage through your or your spouse’s current employment since the first month you were eligible for Medicare Part B. Your coverage must not have ended more than 8 months ago. If you qualify for Medicare because of a disability, you must have large group health plan coverage based on your, your spouse’s or a family member’s current employment.