The Form CMS-L564 has two sections. The applicant completes Section A and the employer,
the GHP or LGHP completes Section B of the form. The information provided in Section
B is the evidence of GHP or LGHP coverage. To view the Form CMS-L564, see HI 00805.340.
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 “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. On Form CMS-L564, the beneficiary
completes Section A and submits it to the employer, GHP or LGHP to complete Section
If the beneficiary wants to have the form mailed to them , provide a field office
(FO) return envelope in the mailing. The form may also be mailed directly to the employer
or GHP. If the FO is assisting the beneficiary with completing the form, only complete
Section A and send the form to the employer or GHP to complete Section B.
Explain to the beneficiary that they should mail or take the completed form to their
local FO for processing.