Obtain evidence of GHP or LGHP coverage from the GHP or LGHP when the claimant is
self-employed (i.e., the employer) as outlined in HI 00805.295. The self-employed beneficiary does not complete the evidence portion (Section B)
of Form CMS-L564.
Offer the beneficiary the option to have the Form CMS-L564 mailed to them or to visit
Medicare.gov to get the form by clicking on the tab “Forms, Help & Resources” and selecting “Get
Medicare Forms.” This tab is located on the top of the screen at the far right. (Medicare.gov/forms-help-and-resources/forms/medicare-forms.html). This is where the beneficiary can find the form for completion.
On Form CMS-L564, the self-employed beneficiary completes Section A and the GHP or
LGHP completes Section B.
Instruct the self-employed beneficiary (or their spouse or family member) with the
association coverage to write:
the self-employed individual’s company name as the “Employer’s Name” in Section A,
the name of the beneficiary requesting the SEP in Section A, number 4; and
the name of the self-employed individual as the “Employee’s Name” in Section A, number
If the person requesting the SEP is the self-employed individual, he or she will list
his or her name in both Section A, numbers 4 and 6.
If the beneficiary wants to have the form mailed to him or her, provide these instructions
on the form and a FO return envelope in the mailing.
Explain to the beneficiary that he or she should mail or take the completed form to
their local FO for processing.