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CMS L564-R297

All people in the United States who are more than 65 years of age are probably familiar with the specific medical care program called Medicare. This program is also used by disabled people younger than the mentioned age. It partly covers the medical costs and is supported by the taxes taken from employers and their workers.

Medicare program offers its patients four degrees of protection:

  • Part A (services in hospitals)
  • Part B (additional services)
  • Part C (broad plans that propose more services than the previous part)
  • Part D (paid medicine).

If you have access to Part A (which is basic and free), you can also get the Part B plan (you will have to spend some dollars on that). If not, you must be an American citizen or a legal US resident for at least five years at the date of your application. The Form CMS-L564 is the one many applicants use to get Part B coverage. Sometimes it also can be found by the number CMS-R297.

To start using this plan, you should apply on a certain date. There are three periods of enrollment when people send applications:

  • Initial (begins 90 days prior to your 65th birthday and finishes 90 days after; also called IEP)
  • General (for those who skipped the IEP deadline, it is possible to sign for the plan in January, February, and March of each year; also called GEP)
  • Special (you can use this period if your employer covers your insurance plan or stopped covering it at some point during the past eight months; also called SEP).

The Form CMS-L564 is developed particularly for the last case; it is used only by those who have their plan covered by the entities where they work. Their spouses can join the plan as well and fill this template out.

This document can be a lifesaver for those who skipped the GEP and IEP deadlines. Being late with the form submission for these periods leads to significant fines. So, if your or your spouse’s employer offers the needed insurance program, we recommend choosing SEP and applying with the document we are reviewing here.

Filling Out the Form

This template is quite easy, and highly likely, you will not need any additional help to create it. Workers have to complete the template’s first part (Section A) and then pass their document to the employers to fill out their block (Section B).

The template is available online; you are not required to order it from anywhere. Although CMS offers the current version on their official site, we suggest using our advanced form-building software for generating legal templates, including the Form CMS-L564, just in a moment.

When the template is downloaded, you can open it and start inserting information there. Use our manual to see how to create the document properly and what to include there.

Enter the Worker’s Data

As you already know, the first section must be completed by applicants or workers. A worker must enter their employer’s name in the first line, then write the date when the form is created on the right. The next field is for the employer’s full address, including the state and postal code.

step 1.1 - enter the worker’s data - filling out cms l564-r297

Below, you shall write your full name and social security number (as an applicant). Under this line, you must indicate the “employee’s” name: either your name or the name of the one whose insurance is covered by the employer (if you are a spouse or a relative of this person and are applying for insurance).

step 1.2 - enter the worker’s data - filling out cms l564-r297

Pass the Papers to the Employer

Now your work is done, and you need to transfer the document to the employer to finish the filling-out process.

As an employer, you must choose between employer group health plans or hours bank arrangements (it depends on the insurance program you have chosen before).

If you need to fill out the first part, state if the applicant is or was covered under the Group Health Plan or not. Mark the suitable box by a cross or tick. If the answer is positive, enter the date when the coverage started. Then, specify if it has already finished (if yes, add the date, too).

Give the terms when the employee was working for your entity (the first and the last day). For workers who are still in your company, write the current date in the relevant line on the right.

Some entities use large group plans due to the entity’s size. If this is the used plan, your applicant is disabled, and the plan was the key payer for your applicant’s medical service for a specific period, write the period here.

step 2.1 - pass the papers to the employer - filling out cms l564-r297

If the second part is chosen, indicate whether the applicant is or was covered with the use of the Hours Bank Arrangement. Answer if there are still reserved hours for the applicant (a “yes” or “no” question). Below, you have to insert the date until these hours remain valid (if there are any). You should write only the month and year.

step 2.2 - pass the papers to the employer - filling out cms l564-r297

Sign the Document

It does not matter which insurance your company uses; you as an employer must sign the form. Write your title under your signature, enter the date of signing, and type your phone number on the block’s right-hand side.

step 3 - sign the document - filling out cms l564-r297

Frequently Asked Questions

Where Should I Deliver the Form?

If you apply for insurance coverage using this form, additionally, you will need to create another document (Form CMS-40B). After you have made all the required papers, you have to deliver them to the Social Security office located in your area. The Social Security Administration (or SSA) official site will advise on the offices’ locations.

SSA offers its help for those who have any doubts regarding the forms’ content or the submission procedure: applicants can either visit the office nearby or call the official Administration numbers provided on the authority’s site.