Social Security Part B Employer Form

State i want part b coverage to begin mm yy in the remarks section of the cms 40b form or the online application.

Social security part b employer form.

Social security is authorized to collect your information under sections 1836 1840 and 1872 of the social security act as amended 42 u s c. A social security benefit verification letter includes. One portion is completed by you and the other is completed by your employer or your spouse s employer. If you re an employer without an hours bank arrangement complete the section called for employer group health plans only.

If you live in puerto rico you will not receive medicare part b medical insurance automatically. Social security and the centers for medicare medicaid services cms need your information to determine if you. You will need to sign up for it during your initial enrollment period or you will pay a penalty. Please call us at 1 800 772 1213 tty 1 800 325 0778 monday through friday between 8 a m.

Many forms must be completed only by a social security representative. To sign up please call our toll free number at 1 800 772 1213 tty 1 800 325 0778 you also may contact your local social security office. Form cms l564 is an employment information form from the social security administration ssa. The social security act as amended 42 u s c.

1395o 1395s and 1395ii for your enrollment in medicare part b. It s used in conjunction with form cms 40b when you apply for medicare part b during a special enrollment period sep. If you are an individual representative payee with a my social security account you should check out our new representative payee portal. The form you are looking for is not available online.

Once section b has been completed by your employer return this form along with your part b application to your local social security office. Once section b has been completed by your employer return this form along with your part b application to your local social security office. Social security and the centers for medicare medicaid services cms need your information to determine if you re entitled to part b. What is form cms l564.

If you re an employer without an hours bank. The employer completes all of section b. 1395o 1395s and 1395ii for your enrollment in medicare part b. It lets you conduct your own business or manage direct deposit wage reporting proof.

The benefit you receive from us. Once section a is completed give this form to your employer to complete section b. If you are already enrolled in medicare part a and you would like to enroll in part b please complete form cms 40b application for enrollment in medicare part b medical insurance if you are applying for medicare part b due to a loss of employment or group health coverage you will also need to complete form cms l564 request for employment information. Or contact your local social security office.

Visit faq ssa gov or call social security to free at 1 800 772 1213 tty 1 800 325 0778 for more information.