Form CMS-L564 at a glance
| Official title | Medicare Request for Employment Information |
| Issued by | Centers for Medicare & Medicaid Services (CMS) |
| Edition | 03/2025 |
| Pages | 2 |
| Fillable fields | 44: 34 text fields, 10 checkboxes |
| OMB number | 0938-0787 |
| Official PDF | cms-l564e.pdf on cms.gov |
| Cost with FillWise | 1 fill |
Counted on Oct 11, 2026 from the official PDF, with the same engine FillWise fills it with.
What is in Form CMS-L564
| Part | What it covers | Pages | Fields |
| Section A | To be completed by person signing up for Medicare Part B (Medical Insurance) | 2 | 13 |
| Section B | To be completed by employer | 2 | 31 |
Fields to watch on Form CMS-L564
- 5 questions answered with a Yes box. FillWise ticks one only when your notes answer it; the rest stay empty for you.
- 28 boxes with a fixed number of characters, such as Applicant’s Social Security Number (SSN) (3), Employee’s SSN (if different) (3), State (2), ZIP code (5). Long numbers are split across them, so check the digits.
How to fill Form CMS-L564 with FillWise
- Open the official PDF from cms.gov in Chrome.
- In the FillWise side panel, paste your notes or attach a photo of a document, and press Fill form.
- Check all 2 pages of the downloaded PDF before anyone signs.
Without the extension: Fill a PDF in your account.
How FillWise handles Form CMS-L564
FillWise fills this form the regular way: the AI reads each field's printed caption, its tooltip and its options, and answers from your notes.
The form has a digital signature field. FillWise leaves it empty: signing is yours.
What to check before you file
- The edition. Agencies replace their forms with new editions. This page describes the 03/2025 edition; check that your copy is still the current one on cms.gov.
- Section B is your employer's: they confirm the coverage and employment dates from their records and sign it. Send the form with your Part B application (CMS-40B) to your local Social Security office.
- Names and numbers character by character; signatures, fees and supporting documents stay with you.
Filling Form CMS-L564 for many people
Bulk fill in your FillWise account takes Form CMS-L564 and a CSV or Excel sheet with one person per row. It fills the first one and stops so you can check the result, then fills the rest and hands back one zip. Each copy costs 1 fill, the same as filling it on its own. How it works step by step: bulk PDF form filling guide.
Cost
Form CMS-L564 has 2 pages, but its fields are on page 2 only, so filling it costs 1 fill: FillWise charges a PDF fill by the pages it fills, one fill per started 5 pages. The free plan starts with 20 fills and then tops back up to 5 fills a week, no card required. Paid plans are on the pricing page.
Privacy
The PDF is filled in your browser; only its field list and your data go to our server for the AI, and nothing is stored. Details: privacy and security.