Where do I send my CMS L564 form?

You must submit Form CMS-L564 along with your Application for Enrollment in Medicare Part B (CMS-40B) directly to your local Social Security office.

Submission Options

• By Mail or Fax: Send the completed forms to your local Social Security administration office. You can find your office's specific address and fax number using the Social Security Office Locator.
• In Person: Drop off the paper documents at your local Social Security office.
• Online: You can apply for Medicare Part B and upload or submit your supporting documents digitally by logging into your personal Social Security Account.

You should send your Medicare documents, such as enrollment forms (like CMS-40B or CMS-L564), directly to your Local Social Security Office or submit them through your online account at SSA.gov.

Where to Send Different Medicare Documents

• Enrollment and Part B Forms (CMS-40B, CMS-L564): Mail or fax these to your local Social Security office. You can find your specific office address using the Social Security Office Locator.
• Original Medicare Claims (CMS-1490S): If you need to file a manual claim yourself, mail your patient request for medical payment form along with itemized bills to your state’s Medicare Administrative Contractor (MAC).
• General Mailings or Inquiries: For official guidance on what to do with specific mail or notices, visit Medicare.gov.
• Railroad Retirement Beneficiaries: If you worked for the railroad, send your documents to the Railroad Retirement Board instead of Social Security.

To fill out Form CMS-L564 (Request for Employment Information), you complete Section A yourself, and your employer completes Section B.

You use this form with Form CMS-40B to sign up for Medicare Part B after age 65 using a Special Enrollment Period (SEP) while avoiding late fees.

Step 1: Fill Out Section A (By You, the Applicant)

You fill out the top portion of the form with your personal details and employer information:

• 1. Employer’s Name: Enter the name of the company providing the health insurance.
• 2. Date Completed: Write the date you fill out Section A.
• 3. Employer’s Address: Provide the street, city, state, and zip code of the employer.
• 4. Applicant’s Name: Print your full legal name (the person applying for Medicare).
• 5. Applicant’s Social Security Number (SSN): Enter your SSN.
• 6. Employee’s Name: Print the name of the person who works for the company.
  • Note: If you are the employee and getting Medicare, repeat your name and SSN from numbers 4 and 5. If you are a dependent spouse covered under your working spouse's insurance, put your spouse's name here.
• 7. Employee’s Social Security Number: Enter the employee’s SSN (same as number 5 if you are the employee; different if it is your spouse's job).

Step 2: Fill Out Section B (By Your Employer)

Give the form to your employer's human resources or payroll department. They must complete Section B:

• Group Health Plan Coverage Dates: They will record the exact start and end dates of your active group health coverage.
• Employment Dates: They will document when the employee started and stopped working for the company.
• Signature: An authorized company official must sign, print their name, list their title, and provide a phone number and date.

Step 3: Submit to Social Security

Once both sections are signed and complete, submit the form along with your Form CMS-40B:

• Online: Log into your personal account via the Social Security Administration portal to upload the documents digitally.
• By Mail or Fax: Send both completed forms to your Local Social Security Office.

The general mailing address for general correspondence and paper forms sent to Official Medicare Contact is Medicare Contact Center Operations, PO Box 1270, Lawrence, KS 66044.

Other Specific Medicare Addresses

• Premium Payments: Mail your Medicare Premium Collection Center payments and coupons to PO Box 790355, St. Louis, MO 63179-0355.
• Claims: If you have Original Medicare, send claim forms to the specific address listed for your state on your claim form's Medicare Administrative Contractor Address Table.
• Federal Headquarters: The main office for the Centers for Medicare & Medicaid Services is located at 7500 Security Boulevard, Baltimore, MD 21244-1850.

You can submit a manual medical claim or reimbursement form by mail using the Patient Request for Medical Payment form (CMS-1490S) along with your itemized bills.

How you submit documents depends on whether you are filing a personal medical claim, enrolling, or responding to a records request:

Submitting a Patient Claim or Reimbursement

• Get the Form: Download and print the Patient Request for Medical Payment form (CMS-1490S).
• Gather Documents: Attach an itemized bill from your doctor or supplier, a letter explaining why you are filing, and any relevant receipts or proof of payment.
• Find Your Contractor: Look at your Medicare Summary Notice (MSN) or check the instructions on the form to find the correct address for your state's Medicare Administrative Contractor (MAC).
• Mail It: Send the physical packet by mail. Medicare generally does not accept patient-filed claims online.
• Deadline: You must mail the claim within 12 months (1 year) of the date you received the service.

Submitting Enrollment or Proof Documents (Part B / Special Enrollment)

• Online: Log into your Social Security Administration Account to upload forms like the CMS-L564 (Request for Employment Information) and CMS-40B.
• Alternative Methods: You can also submit enrollment proof via fax, mail, or in person at your local Social Security office.

For Healthcare Providers (esMD / ADR)

• Electronic Submission: Providers responding to an Additional Documentation Request (ADR) can submit files securely via the esMD system or a designated MAC provider portal.
• Alternative Methods: Providers can also submit via fax, mail, or physical media (CD/USB) following specific regional instructions.