Summary
Overview
Work History
Education
Skills
Accomplishments
Additional Information
Timeline
Cashier

Rosemary Contreraz

Cashier/ Service desk
Bullhead City,AZ

Summary

  • To be completed by individual signing up for Medicare Part B (Medical Insurance) 1. Employer’s Name 2. Date / / 3. Employer’s Address City State Zip Code 4. Applicant’s Name 5. Applicant’s Social Security Number – – 6. Employee’s Name 7. Employee’s Social Security Number – – SECTION B: To be completed by Employers

Overview

16
16
years of professional experience

Work History

Cashier

Menards
Buffalo , MM
04.2006 - 06.2022
  • Form CMS L564/R297 (08/20) 1, CENTERS FOR MEDICARE & MEDICAID SERVICES
  • Form Approved
  • OMB No
  • 0938-0787
  • REQUEST FOR EMPLOYMENT INFORMATION
  • WHAT IS THE PURPOSE OF THIS FORM?
  • In order to apply for Medicare in a Special Enrollment
  • Period, you must have or had group health plan coverage within the last 8 months through your or your spouse’s current employment
  • People with disabilities must have large group health plan coverage based on your, your spouse’s or a family member’s current employment
  • This form is used for proof of group health care coverage based on current employment
  • This information is needed to process your Medicare enrollment application
  • The employer that provides the group health plan coverage completes the information about your health care coverage and dates of employment
  • HOW IS THE FORM COMPLETED?
  • Complete the first section of the form so that the employer can find and complete the information about your coverage and the employment of the person through which you have that health coverage
  • The employer fills in the information in the second section and signs at the bottom
  • WHAT DO I DO WITH THE FORM?
  • Fill out Section A and take the form to your employer
  • Ask your employer to fill out Section B
  • You need to get the completed form from your employer and include it with your
  • Application for Enrollment in Medicare (CMS-40B)
  • Then you send both together to your local Social Security office
  • Find your local office here: www.ssa.gov
  • GET HELP WITH THIS FORM
  • Phone: Call Social Security at 1-800-772-1213
  • En español: Llame a SSA gratis al 1-800-772-1213 y oprima el 2 si desea el servicio en español y espere a que le atienda un agente
  • In person: Your local Social Security office
  • For an office near you check www.ssa.gov
  • You have the right to get Medicare information in an accessible format, like large print, Braille, or audio
  • You also have the right to file a complaint if you feel you’ve been discriminated against
  • Visit https://www.medicare.gov/about-us/accessibility-nondiscrimination-notice, or call 1-800-MEDICARE (1-800-633-4227) for more information
  • TTY users can call 1-877-486-2048
  • Expires: 06/2023
  • Form CMS L564/R297 (08/20) 2, & MEDICAID SERVICES
  • Form Approved
  • OMB No
  • 0938-0787

Plans
  • 1
  • Is (or was) the applicant covered under an employer group health plan
  • Yes No 2
  • If yes, give the date the applicant’s coverage began
  • (mm/yyyy) / 3
  • Has the coverage ended
  • Yes No 4
  • If yes, give the date the coverage ended
  • (mm/yyyy) / 5
  • When did the employee work for your company?
  • From: (mm, Still Employed: (mm/, 6
  • If you’re a large group health plan and the applicant is disabled, please list the timeframe (all months) that your group health plan was primary payer
  • From: (mm/yyyy) /, Hours Bank Arrangements ONLY: 1
  • Is (or was) the applicant covered under an Hours Bank Arrangement
  • Yes No 2
  • If yes, does the applicant have hours remaining in reserve
  • Yes No 3
  • Date reserve hours ended or will be used
  • (mm/yyyy) /
  • All Employers

Signature of Company Official
, MD
  • Title of Company Official Phone Number ( ) –
  • According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number
  • The valid OMB control number for this information is 0938-0787
  • The time required to complete this information collection is estimated to average 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection
  • If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05,
  • Baltimore, 21244-1850
  • 3INSTRUCTIONS: Form CMS L564/R297 (08/20)
  • Form Approved
  • OMB No
  • 0938-0787
  • STEP BY STEP INSTRUCTIONS FOR THIS FORM
  • SECTION A:
  • The person applying for Medicare completes all of
  • Section A
  • 1
  • Employer’s name:
  • Write the name of your employer
  • 2
  • Date:
  • Write the date that you’re filling out the Request for
  • Employment Information form
  • 3
  • Employer’s address:
  • Write your employer’s address
  • 4
  • Applicant’s Name:
  • Write your name here.

Education

St Michael
Chicago, IL
06.1972

Skills

  • Credits and Refunds
  • Customer Transactions
  • Shipment Procedures
  • Feedback Acceptance
  • Inventory Stocking
  • Sweeping and Mopping
  • Gift Wrapping
  • Cooperative Attitude
  • Product Location
  • Cash Register Operation
  • Customer Relations
  • Work Task Prioritization
  • Price Identification
  • Cash Drawer Management
  • Cashier Abilities
  • Guest Satisfaction
  • Customer Assistance
  • Check Cashing
  • PCI (Payment Card Industry)
  • Promoting Loyalty
  • Bagging and Packaging
  • Stocking and Replenishing
  • Belt Conveyors
  • Resolving Discrepancies
  • Positive Interactions
  • Checks Validation
  • Janitorial Duties
  • Monetary Transactions
  • Smoothie Making
  • Collecting Carts
  • Folding Clothes
  • Answering Customer Questions
  • Basic Math Functions
  • Identification Checks
  • Location Skills
  • Suggestive Selling
  • Shelving Items
  • Guest Inquiries
  • Coin and Currency Counting
  • Total Payment Calculation
  • Checking Out Customers
  • Return and Exchange Processing
  • Verifying Eligibility
  • Social Perception
  • Telephone Reception
  • Coupon Redemption
  • Guest Flow
  • Service Minded
  • Ticket Sales
  • Membership Programs
  • Signage Updates
  • Counter Sanitization
  • Energetic and Outgoing
  • Reading Comprehension
  • Adaptable and Flexible
  • Schedule Optimization
  • Speaking Clearly
  • Collaborative Relationships
  • Corrective Actions

Accomplishments

  • ONLY”
  • 2
  • If yes, does the applicant have hours remaining in reserve?
  • Please indicate if the applicant currently has health coverage based on the remaining hours in the employee’s hours bank account
  • 3
  • Date reserve hours ended or will be used?
  • Please write the month and year for when the remaining hours in the employee’s hours bank account expired or will expire
  • All employers need to complete the bottom of
  • Section B
  • Signature of Company Official:
  • An official representative of the company needs to sign this document
  • Please do not print
  • Date Signed:
  • Write the date that you sign the form in this field
  • Title of Company Official:
  • Print the title of the company official who signed the form in this field
  • Phone Number:
  • Write the phone number of the company official who signed the form in this field
  • If there are questions regarding the information on this form, a representative from Social Security will contact you.

Additional Information

  • The employer completes all of Section B. If you’re an employer without an hours bank arrangement, complete the section called “For Employer Group Health Plans ONLY” 1. Is (or was) the applicant covered under an employer group health plan? Please check yes or no if the applicant was covered under your group health plan offered by your company. The applicant may be the employee or another person related to the employee, such as a spouse or family member with disabilities. If your company doesn’t offer a group health plan, please check No. A group health plan is any plan of one or more employers to provide health benefits or medical care (directly or otherwise) to current or former employees, the employer, or their families. 2. If yes, give the date the coverage began. Write the month and year the date the applicant’s coverage began in your group health plan. 3. Has the coverage ended? Check yes or no if the group health plan coverage for the applicant has ended. 4. If yes, give the date the coverage ended. Write the month and year the group health plan coverage ended for the applicant. 5. When did the employee work for your company? Write the start and end dates of the employment for the employee in which the applicant is related. It may be the applicant or another person related to the employee, such as a spouse or family member with disabilities. Enter the month and year of the start of the employment in the “From” box. Enter the month and year of end of the employment in the “To” box. If the employee is still employed, enter the month and year of the current date. Current employment is active working status. It is not disability or retirement. 6. If you’re a large group health plan and the applicant is disabled, please list the timeframe (all months) that your group health plan was primary payer. Write the start and end dates that your group health plan was primary payer for the applicant. If you’re an employer with an hours bank arrangement, complete the section called “For Hours Bank Arrangements ONLY” 1. Is (or was) the applicant covered under an hours bank arrangement? Please check yes or no if the applicant was covered under an hours bank arrangement. If you check no, please also fill out the section for “Employer Group Health Plans

Timeline

Cashier

Menards
04.2006 - 06.2022

Plans

Signature of Company Official

St Michael

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Rosemary Contreraz Cashier/ Service desk