This form contains 9 fields organized into 3 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name	Type	Description
Current Employment Information
Current Facility Name	Text	Please provide the name of the facility where the employee is currently employed.
Current Facility Provider ID	Text	Please provide the provider identification number for the facility where the employee is currently employed.
Date of Current Employment	Date	Please provide the start date of the employee's current employment.
Employee Information
Employee Name	Text	Provide the full name of the employee.
Social Security Number	Text	Provide the Social Security Number of the employee.
Previous Employment Information
Previous Facility Name	Text	Enter the full name of the facility where the individual was previously employed.
Previous Facility Provider ID	Text	Provide the Provider ID of the facility where the individual was previously employed, if known.
Previous Facility Address	Text	Enter the full street address, city, state, and zip code of the facility where the individual was previously employed.
Previous Employment End Date	Date	Enter the date when the previous employment ended.

Form CMS-L564, Request for Employment Information Instructions