Where do you live?
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
DC
801-523-6081
Español
Education
Decision Support
Webinars
Resources
Blog
Important Forms
HR
Contact
Menu
Education
Decision Support
Webinars
Resources
Blog
Important Forms
HR
Contact
Home
>
Forms
>
Medicare
>
Request for Employment Information Form (CMS L564)
Request for Employment Information Form (CMS L564)
This is used to verify employment for those signing up for Medicare after 65 due to being covered by an employer plan.
Download Form
