If you have recently lost group employee health insurance coverage and are 65 or over and need to sign up for Medicare, you can submit your applications by FAX to help speed up the process. You must fill out an Application for Enrollment in Medicare Part B and also the Request for Employment Information forms.

The application can be downloaded at https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS40B-E.pdf and the request for employment information form can be downloaded at https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS-L564E.pdf.

Be sure and indicate in the “Remarks” section of the application your desired effective date which will always be the first of the month, i.e., if you are applying in May, request an effective date of June 1. Also, if you cannot obtain your employer’s signature, the following alternatives will suffice.

When completing the CMS L564

  • State on the form “I want Part B coverage to begin (MM/YY)”
  • If possible, your employer should complete Section B.
  • If your employer is unable to complete Section B, please complete that portion on behalf of your employer without your employers signature and submit one of the following forms of secondary evidence:
    • income tax form that shows health insurance premiums paid;
    • W-2s reflecting pre-tax medical contributions;
    • pay stubs that reflect health insurance premium deductions;
    • health insurance cards with a policy effective date;
    • explanations of benefits paid by the GHP or LGHP; or
    • statements or receipts that reflect payment of health insurance premiums.

Once completed, the forms can be faxed to Social Security at 1-833-914-2016.

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