New to Medicare?How to sign up, step by step: turning 65 or coming off a work plan, forms includedSee the sign-up steps
(435) 260-3200 Medicare Intake Book your appointment
Medicare Annual EnrollmentAEP is open — ends Dec 7 Book a free callBook →

Leaving employer coverage

Fill out your Part B forms

Answer a few questions and we'll fill in forms CMS-40B and CMS-L564 for you. Then download them, sign, and send them to Social Security.

Rather have us do it?

Send your answers to Medicare On Main and we'll fill out both forms for you, then call to go over them before you sign.

Have us fill them out for me ↗

Or do it yourself below, privately. Your Social Security number, Medicare number and job details stay on this device. We only receive your name and how to reach you, so we can help if you get stuck.

1 About you
Do you already have Medicare Part A? Most people do. It usually starts on its own at 65 if you collect Social Security, or you signed up for it.
2 The job with the health coverage
Whose job was it?
Is that health coverage from a job you (or your spouse) still have?
Has an employer or insurer required you to sign up for Part B?
3 When should Part B start?

If you're still on the employer plan (or in your first full month off it), you can choose the start date. Most people want Part B to begin the 1st of the month after the employer coverage ends, so there's no gap.

By clicking, you agree Medicare On Main may call, text or email you about your Medicare enrollment. You're not required to buy anything. Msg & data rates may apply; reply STOP to opt out.

About these forms

Is it safe to type my Social Security number here?

Your Social Security number, Medicare number, employer and dates are written into the PDF by your own browser and are never sent to us or anyone else. The only thing that reaches Medicare On Main is your name, phone, email and ZIP, so we can call if you want help signing and sending the forms.

Who fills out Section B of the CMS-L564?

Your employer's HR or benefits office. You fill in Section A (this page does that for you), then hand the form to your employer to confirm your group health coverage and sign.

Where do I send the finished forms?

To Social Security. You can upload them through Social Security's online Part B application, or fax or mail them to your local Social Security office. Keep copies.

What if I don't have Medicare Part A yet?

Then you don't need form CMS-40B. You apply for Part A and Part B together online at Social Security, the same way people turning 65 do, and send a CMS-L564 signed by your employer. Answer "No, not yet" to the Part A question and this page fills out just the CMS-L564.

Last updated . Maintained by the Medicare On Main Data Desk · reviewed by Brian Penner, Independent Medicare advisor (NPN 16493717).