Middlesex Massachusetts Employment Information Document with Insurance Information
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How to fill out Middlesex Massachusetts Employment Information Document With Insurance Information?
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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.
CMS 40B. Form Title. Application for Enrollment in Medicare - Part B (Medical Insurance) Revision Date.
Fill out Form CMS-40B (Application for Enrollment in Medicare Part B). Send the completed form to your local Social Security office by fax or mail. Call 1-800-772-1213. TTY users can call 1-800-325-0778.
You can find your local Social Security office by clicking SSA Office Locator under the Related Links section below. Your employer doesn't need to sign Section B of the CMS L564 form. State I want Part B coverage to begin (MM/YY) in the remarks section of the CMS 40B form or the online application.
CMS L564. Form Title. REQUEST FOR EMPLOYMENT INFORMATION. Revision Date. 2020-05-26.
This information is needed to determine whether an individual is eligible to enroll in Medicare Part B or Premium Part A under the provisions of section 1837(i) of the Social Security Act (The Act) and/or qualify for a reduction in the premium amount under the provisions of section 1839(b) of the Act.
Fill out Section A and take the form to your employer. Ask your employer to fill out Section B. You need to get the completed form from your employer and include it with your Application for Enrollment in Medicare (CMS-40B). Then you send both together to your local Social Security office.
The Centers for Medicare & Medicaid Services (CMS) is a Federal agency within the U.S. Department of Health and Human Services. Many CMS program related forms are available in Portable Document Format (pdf).
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