Form CMS-L564, Request for Employment Information Completed Form Examples and Samples
Explore practical examples and samples of Form CMS-L564, Request for Employment Information. Learn how to accurately complete this Medicare form with our detailed guides and automated processing use cases.
Automated Processing of Form CMS-L564: Request for Employment Information
How this form was filled:
This example demonstrates how an AI agent extracts critical employment details from unstructured HR correspondence to populate the CMS-L564 Request for Employment Information form. By parsing natural language, the system accurately maps specific employee and facility data into the formal government structure, streamlining the verification process.
Source document used: HR Onboarding/Transition Email
Subject: Onboarding Documentation - Sarah Jenkins - Employee ID #99283 Dear Payroll Department, I am writing to finalize the transition paperwork for our new hire, Sarah Jenkins. She joined our team here at Oakwood Senior Living, located at 450 Maple Avenue, Springfield, IL 62704, on February 15, 2026. For our internal records and the CMS-L564 certification process, we have verified that our facility provider ID is 88-3421-B. Regarding her previous work history, Sarah provided documentation indicating that she concluded her tenure at her former employer, St. Jude’s Nursing Center, on January 30, 2026. St. Jude’s is located at 1200 Health Parkway, Suite 10, Chicago, IL 60601, and their provider ID is 55-9002-X. Please ensure these details are reflected in the request for employment information filing so that her benefits coordination is processed without delay. Sarah’s social security number for the file is 000-45-9872. Please let me know if you require any additional signatures or digitized copies of her credentials before we submit the final packet to the carrier. We want to ensure she is fully integrated into our health plan by the end of this month. Best regards, Marcus Thorne, Human Resources Manager.
Information used to fill out the document:
- Employee: Sarah Jenkins (SSN: 000-45-9872)
- Previous Employment: St. Jude’s Nursing Center, 1200 Health Parkway, Chicago, IL 60601 (ID: 55-9002-X), ended 01/30/2026
- Current Employment: Oakwood Senior Living, 450 Maple Avenue, Springfield, IL 62704 (ID: 88-3421-B), started 02/15/2026
What this filled form sample shows:
- Intelligent identification of facility provider IDs versus general addresses
- Normalization of date formats from narrative text to standardized fields
- Extraction of PII (SSN) while maintaining data security protocols
- Contextual separation of current and previous employer details within a single narrative
- Disambiguation of similar entities (Nursing Center vs Senior Living)
Form specifications and details:
| Form: | CMS-L564 |
| Form Title: | Request for Employment Information |
| Target Use Case: | Verification of prior and current employment for health insurance/benefits eligibility |
| Industry: | Healthcare Administration |
| Keywords: | Form CMS-L564, Request for Employment Information example, how to fill Form CMS-L564, employment verification |
| Categories: | CMS forms, employment forms |
| Created: | May 25, 2026 10:56 PM |