WHAT IS THE PURPOSE OF FORM L564

In order to apply for Medicare in a Special Enrollment Period, you must have or had group health plan coverage within the last 8 months through your or your spouse’s current employment. People with disabilities must have large group health plan coverage based on your, your spouse’s or a family member’s current employment. This form is used for proof of group health care coverage based on current employment. This information is needed to process your Medicare enrollment application. The employer that provides the group health plan coverage completes the information about your health care coverage and dates of employment.

WHEN DO YOU USE FORM 40B

Use this form:

• If you’re in your IEP and refused Part B or did not sign up when you applied for Medicare, but now want Part B.

• If you want to sign up for Part B during the General Enrollment Period (GEP) from January 1 – March 31 each year.

• If you refused Part B during your IEP because you had group health plan (GHP) coverage through your or your spouse’s current employment. You may sign up during your 8-month Special Enrollment Period (SEP).

• If you have Medicare due to disability and refused Part B during your IEP because you had group health plan coverage through your, your spouse or family member’s current employment.

• You may sign up during your 8-month SEP.