Use this form if someone is DELAYING part B enrollment. They will need to get this filled out by their employer showing they had creditable coverage and attach this to their Part B application
[https://www.dropbox.com/scl/fi/4i2l7l7h52qpysisfplri/CMS-L564.pdf?rlkey=kqwbkl6yyajdjqbnigdizty21&st=w0r613rc&dl=0](https://www.dropbox.com/scl/fi/4i2l7l7h52qpysisfplri/CMS-L564.pdf?rlkey=kqwbkl6yyajdjqbnigdizty21&st=w0r613rc&dl=0)