Download a form, learn more about a letter you got in the mail, or find a publication. HEALTH INSURANCE You must report all health insurance you have now.PAYERID number exists, then enter the Medigap insurance program or plan name. • Complete Form A if anyone applying for medical benefits has Medicare or other health insurance. Complete this Block if you are age 65 or older and enrolled in a health insurance plan where your spouse is currently working. Authorization to Disclose Personal Health Information" Form. Publications then Forms, then refer to Medicare Intermediary Section). • Current Illinois Department of Nuclear Safety approval letter – can be obtained by. If the employer can't fill it out, complete Section B of the CMS-L564 form as best you can, but don't sign it. Your letter may say you need to complete a renewal form in order to keep your coverage.