Form CMS L564, Request for Employment Info Instructions

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This form contains 48 fields organized into 8 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name Type Description
Applicant Name and Social Security Number
Applicant's Full Name Text
Enter the applicant's full legal name (first name, middle initial if any, and last name) exactly as it appears on official records.
Applicant SSN — First 3 Digits Text
Enter the first three digits of the applicant's Social Security Number (the initial group of numbers).
Max length: 3 characters
Applicant SSN — Middle 2 Digits Text
Enter the middle two digits of the applicant's Social Security Number (the second group of numbers).
Max length: 2 characters
Applicant SSN — Last 4 Digits Text
Enter the last four digits of the applicant's Social Security Number (the final group of numbers).
Max length: 4 characters
Company Official Signature, Date and Contact
Date Signed — Month Date
Enter the month in which the company official signed this form.
Max length: 2 characters
Date Signed — Day Date
Enter the day of the month when the company official signed this form.
Max length: 2 characters
Date Signed — Year Date
Enter the year when the company official signed this form.
Max length: 4 characters
Title of Company Official Text
Enter the official job title of the company official signing the form (for example, 'HR Manager' or 'Benefits Administrator').
Phone Number — Area Code Text
Enter the company official's telephone area code (first three digits).
Max length: 3 characters
Phone Number — Prefix Text
Enter the middle three digits of the company official's telephone number.
Max length: 3 characters
Phone Number — Line Number Text
Enter the last four digits of the company official's telephone number.
Max length: 4 characters
Employee Name and Social Security Number
Employee Name Text
Enter the employee's full legal name (first name, middle initial if any, and last name) as it appears on official records.
Employee SSN — First 3 Digits Text
Enter the first three digits of the employee's Social Security Number.
Max length: 3 characters
Employee SSN — Middle 2 Digits Text
Enter the middle two digits of the employee's Social Security Number.
Max length: 2 characters
Employee SSN — Last 4 Digits Text
Enter the last four digits of the employee's Social Security Number.
Max length: 4 characters
Employer Address (Street, City, State, Zip)
Employer Street Address Text
Enter the employer's full street address, including building number, street name, and apartment or suite number if applicable.
Employer City Text
Enter the city in which the employer's address is located.
Employer State Text
Enter the state where the employer is located (use the two-letter postal abbreviation or full state name).
Max length: 2 characters
Employer ZIP Code Text
Enter the employer's postal ZIP code (5-digit ZIP or ZIP+4 if available).
Max length: 5 characters
Employer Group Health Plan Details
Applicant covered under employer group health plan — Yes Checkbox
Check this box if the applicant is or was covered under an employer group health plan.
Applicant covered under employer group health plan — No Checkbox
Check this box if the applicant was not covered under an employer group health plan.
Coverage Begin - Month Text
Enter the month (MM) when the applicant's employer group health coverage began. Fill only if 'Applicant covered under employer group health plan — Yes' Fill only if Employer Group Health Plan question is 'Yes'.
Max length: 2 characters
Depends on: Applicant covered under employer group health plan — Yes
Coverage Begin - Year Text
Enter the year (YYYY) when the applicant's employer group health coverage began. Fill only if 'Applicant covered under employer group health plan — Yes' Fill only if Employer Group Health Plan question is 'Yes'.
Max length: 4 characters
Depends on: Applicant covered under employer group health plan — Yes
Has the coverage ended — Yes Checkbox
Check this box if the applicant’s employer group health plan coverage has ended. Fill only if 'Applicant covered under employer group health plan — Yes' Fill only if Employer Group Health Plan question is 'Yes'.
Depends on: Applicant covered under employer group health plan — Yes
Has the coverage ended — No Checkbox
Check this box if the applicant’s employer group health plan coverage has not ended (coverage is still active). Fill only if 'Applicant covered under employer group health plan — Yes' Fill only if Employer Group Health Plan question is 'Yes'.
Depends on: Applicant covered under employer group health plan — Yes
Coverage End - Month Text
Enter the month (MM) when the applicant's employer group health coverage ended, if applicable. Fill only if 'Has the coverage ended — Yes' Fill only if Has the coverage ended? is 'Yes'.
Max length: 2 characters
Depends on: Has the coverage ended — Yes
Coverage End - Year Text
Enter the year (YYYY) when the applicant's employer group health coverage ended, if applicable. Fill only if 'Has the coverage ended — Yes' Fill only if Has the coverage ended? is 'Yes'.
Max length: 4 characters
Depends on: Has the coverage ended — Yes
Employment From - Month Text
Enter the month (MM) when the employee began working for your company.
Max length: 2 characters
Employment From - Year Text
Enter the year (YYYY) when the employee began working for your company.
Max length: 4 characters
Employment To - Month Text
Enter the month (MM) when the employee stopped working for your company, if applicable.
Max length: 2 characters
Employment To - Year Text
Enter the year (YYYY) when the employee stopped working for your company, if applicable.
Max length: 4 characters
Still Employed - Month Text
If the employee is still employed, enter the most recent month (MM) of employment.
Max length: 2 characters
Still Employed - Year Text
If the employee is still employed, enter the most recent year (YYYY) of employment.
Max length: 4 characters
Primary Payer (Disabled) From - Month Text
If the applicant is disabled and your large group plan was the primary payer, enter the starting month (MM) of that timeframe.
Max length: 2 characters
Primary Payer (Disabled) From - Year Text
If the applicant is disabled and your large group plan was the primary payer, enter the starting year (YYYY) of that timeframe.
Max length: 4 characters
Primary Payer (Disabled) To - Month Text
If the applicant is disabled and your large group plan was the primary payer, enter the ending month (MM) of that timeframe.
Max length: 2 characters
Primary Payer (Disabled) To - Year Text
If the applicant is disabled and your large group plan was the primary payer, enter the ending year (YYYY) of that timeframe.
Max length: 4 characters
Employer Name and Date
Employer's Name Text
Enter the full name of the employer (current or most recent) as it appears on employment records.
Date — Month Date
Enter the month portion of the date when you completed this section of the form.
Max length: 2 characters
Date — Day Date
Enter the day portion of the date when you completed this section of the form.
Max length: 2 characters
Date — Year Date
Enter the year portion of the date when you completed this section of the form.
Max length: 4 characters
Hours Bank Arrangement Details
Applicant covered under Hours Bank Arrangement — Yes Checkbox
Check this box if the applicant is or was covered under an Hours Bank Arrangement.
Applicant covered under Hours Bank Arrangement — No Checkbox
Check this box if the applicant was not covered under an Hours Bank Arrangement.
Applicant has hours remaining in reserve — Yes Checkbox
Check this box if the applicant (under the Hours Bank Arrangement) still has hours remaining in reserve. Fill only if 'Applicant covered under Hours Bank Arrangement — Yes' Fill only if Hours Bank Arrangement question is 'Yes'.
Depends on: Applicant covered under Hours Bank Arrangement — Yes
Applicant has hours remaining in reserve — No Checkbox
Check this box if the applicant does not have any hours remaining in reserve. Fill only if 'Applicant covered under Hours Bank Arrangement — Yes' Fill only if Hours Bank Arrangement question is 'Yes'.
Depends on: Applicant covered under Hours Bank Arrangement — Yes
Reserve End Month Date
Enter the month when the reserve hours ended or will be used for the hours bank arrangement. Fill only if 'Applicant has hours remaining in reserve — Yes' Fill only if Does the applicant have hours remaining in reserve? is 'Yes'.
Max length: 2 characters
Depends on: Applicant has hours remaining in reserve — Yes
Reserve End Year Date
Enter the year when the reserve hours ended or will be used for the hours bank arrangement. Fill only if 'Applicant has hours remaining in reserve — Yes' Fill only if Does the applicant have hours remaining in reserve? is 'Yes'.
Max length: 4 characters
Depends on: Applicant has hours remaining in reserve — Yes
Validation
Signature1 Signature
Provide your signature to validate the information provided in this form.