CMS-L564, request for employment information
Download CMS-L564 and have the employer complete Section B before combining it with the Medicare enrollment package.
Prepare my formLetters from $3.20 with printing and First-Class postage included. See all prices
Check the official form requirements
Download the current CMS-L564, then complete and sign it outside IRIS. Use IRIS for the finished PDF only when the agency's required filing method and the acceptable-use policy permit a printed PDF.
IRIS is an independent printing and mailing service. It is not USPS or Centers for Medicare & Medicaid Services. Review the document, destination, mailing options, and total before checkout.
Read the current Centers for Medicare & Medicaid Services instructionsLoading the document tools…