Medicare Part A & B

Enrolling more than 3 months past 65th birthday

Since you did not enroll in Parts A & B when you first became eligible, you will have to submit documentation to show you had creditable coverage from your 65th birthday. You will need the Request for Employment Information to apply.

Send this to your employer first for completion. See more information below about completing this form.
Once you receive the completed copy back from your employer, you can apply for Medicare.

Apply Online
You will need your completed (and signed by HR) Request for Employment Information Form in front of you for the application because you will need to key in all of the fields completed on this form.

The easiest way to enroll is to visit www.ssa.gov/medicare. Scroll Down to find the button for Apply for Medicare Only (or click here to go right to the application)
- In the notes/comments section please write: “I would like my Medicare Part B to be effective__/1/202__. I have completed a CMS-L564 (Request for Employment Information Form) signed by my employer. I will fax this form along with my Part B application to my local social security office for processing.”
  - We recommend printing a copy of your submitted online application and faxing it in with your Employer form. The fax number can be found by clicking on the link.
Please keep any email confirmation receipts and check your www.myssa.gov to check status on the processing. If you not see Medicare Parts A&B populate in your www.myssa.gov account prior to your effective date request, please contact your Social Security office to confirm that they are in receipt of your application.
Apply under a spouse's tax history
If you are applying for Medicare, but do not have 40 quarters of Medicare taxes due to your own history, you will have to apply under your spouses taxes and work history.

Under this circumstance, please contact your Social Security office to explain your situation and request enrollment in Medicare.
- You may be asked for additional documentation such as your marriage certificate when you apply.

Do you need your Medicare number, but haven’t received your ID Card yet?

If you do not receive your ID card, please contact HTA and we can help you find your Medicare number online. You can also look for it yourself by logging into www.ssa.gov, but can be tricky to find. Here is are some screen shots to show you what to look for when trying to find your Medicare number online.

More information on the Request For Employment Information

This form is necessary to show you have a valid enrollment period and to avoid a Medicare Part B late enrollment penalty.

Please take this form to the Human Resources Department to complete.
You will need a form completed for each spouse that wishes to apply for Medicare.
The form confirms you have had creditable coverage since you turned age 65, which will show that you are eligible for enrollment; as well as, waive a late enrollment penalty.

Creditable coverage is verified on the form by:

The dates the Employee was Actively Employed.
The date you were covered under the Group Health Plan.
The start date should reflect the initial enrollment in group coverage NOT the date of your last enrollment period.

If you have not been covered under the same employer since you turned age 65, you will need an Employment Verification Form from each employer that provided you group coverage.

If your employer is out of business or unable to sign this form, other acceptable verifying documents may be accepted. Contact HTA if you need a list of other acceptable types of documentation.

Medicare Part A & B

Enrolling more than 3 months past 65th birthday

Do you need your Medicare number, but haven’t received your ID Card yet?

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