Form CMS-L564 is a form used by the Social Security Administration to grant a special filing deadline to Medicare recipients who initially refused Part B coverage because they received group health benefits from their employer or a spouse`s employer. You must submit your FORM CMS-L564 and your form CMS-40B at the same time. You can send the forms by mail or in person to your local Social Security office. You can also fax the CMS-40B and CMS-L564 to 1-833-914-2016. or mail the forms back to your local social security office. Please contact Social Security at 1-800-772-1213 (TTY 1-800-325-0778) if you have any questions. The official government website for Medicare provides more information about Medicare enrollment deadlines and the specific enrollment period that applies to Form CMS-L564. Me too. Where is the secure fax (anti-fraud) telephone number for filing Form SSA-1696? You can complete Form CMS-40B (Application for Medicare Registration – Part B [Health Insurance]) and CMS-L564 (Application for Employment Information) online. Important Note: If you don`t already have Medicare Part A, you don`t need to fill out Form CMS-40B.

You must contact Social Security directly at 1-800-MEDICARE (1-800-633-4227) TTY: 1-877-486-2048. Section B must be completed by the employer. Once you have completed section B of the form, you can submit the completed form. You will need the following information for Section A: After you and the employer have completed Part A and Part B of Form CMS-L564, you may submit the form with your Medicare application (Form CMS-40B). Hello, I tried to reactivate my dad`s Medicare Part B plan because we have already paid the premium. So we downloaded and finished the SSA-795, as one of the SSA representatives said. So we looked for the fax number to fax the papers. So I can get the fax number from the SSA office located at 1380 Parker Street, Bronx, NY-10462 Hi Robert, thank you for using our blog. Call your local social security office. Please look for the phone number of the general request in the locator of the Social Security office. The number may appear under View additional Office information.

Please note that our wait times are longer than normal. We hope this information will help you. Before you are no longer enrolled in this employer-sponsored group health insurance plan, you may want to enroll in Medicare Part B. To do this, you must be eligible for a special registration period (SEP). If you are applying for Medicare, you must complete Form CMS-L564 with your Medicare application. Form CMS-40B is your actual Medicare Part B application and requires the following information: Some people reject Medicare Part B if they are eligible for it for the first time because they are still enrolled in health insurance from their employer or a spouse. For many people, signing up for Medicare Part B doesn`t mean you`re leaving the comfort of home. Please visit our Medicare Part B website if: Compare multiple Medicare Advantage plans side by side.

Please let your friends and family know about this option online, by mail or fax. Medicare includes a long list of special enrollment times for various circumstances. Form CMS-L564 is valid for a specific registration period granted to individuals who have employer-sponsored health insurance or who have recently lost. These beneficiaries may use a specific enrolment period to enroll in Part B if they are still covered by the group plan or if they have been covered by the group plan in the last eight months. Form CMS-L564 consists of two sections, both of which must be completed. You need to fill in section A and the employer will fill in section B. Hi Shahrear, please use our blog. Use our Social Security Office Locator to get the fax number of your local office. We hope this helps! You can use this printable version of the CMS-L564 form provided by the official government website for Medicare. .