Form RL-380-F Report of Medical State Office on Beneficiary's Buy-In S

Form Approved
OMB NO.3220-0185

RRB Claim Number

Send reply to:
U.S. RAILROAD RETIREMENT BOARD

Medicare Claim Number
Beneficiary's Own Social Security Number
Beneficiary's DOB

Sex:
Male
Female
Social Security Claim Number

Report of Problem:
Buy-in Accretion Alleged

Medicaid Number

Buy-in Deletion Alleged

Beneficiary's Name

Other:

Beneficiary's Address:

Signature of RRB Employee

Title

Telephone Nurr~ber

Date

To be Completed by State Representative
Information from State Records or Action Being Taken by State
(See Important Notices on the Next Page)

1.

State has been paying Medicare premium since
(MonthNear)

2.

State paid Medicare premium from

through
(MonthNear)

3.

Beneficiary died
(IVlonthNear)

(MonthNear)

UNITEDSTATES
RAILROAD
RETIREMENT
BOARD - 2

Form Approved OMB No. 3220-0 185

4.

Claim number under which state paid premium (if different from RRB Medicare claim number)

5.

State will submit a buy-in accretion effective
exchange with CMS.
(MonthNear)

6.

State will submit a buy-in deletion effective
(MonthNear)
exchange with CMS.

in the

data
(MonthNear)

in the

data
(Monthwear)

7.

Buy-in problem case on this beneficiary was submitted to ClVlS on
. Allow
days for resolution.
(MonthNear)

8.

Beneficiary never eligible for buy-in.

9.

State has no record of this beneficiary. Beneficiary should contact the following office and file
a Medicaid application.

10.

RRB inquiry has been referred to the office listed in item 9 above.

11.

Other:

Signature of State Representative

Title

Printed Name

Telephone Number

Date

Please Return This Form to the Railroad Retirement Board
at the Address Shown on the First Page.
Paperwork Reduction Act Notice

This notice is iven under the Paperwork Reduction Act of 1995. Under Section 7(d) of the Railroad
Retirement AC! (RRA), the Railroad Retirement Board RRB is authorized to collect the information
requested on th,is form. The information is needed b t e R B to determine the eligibility of an individual
receiving benefits under the RRA for the payment of \is or her Medicare medical insurance (Part B)
premiums b the State. The information is also used by the RRB to determine if we should stop premium
deductions k r Medicare medical insurance from the benefits paid to the individual. Your obligation to
provide us with this information is required under the law.
We estimate this form takes an average of 10 minutes to complete, including the time for reviewing the
completed response. Federal agencies may not conduct or s onsor, and respondents are not required to
respond to a collection of information unless it displays a vali OMB number. If you wish, send comments
regard1rl.g the accuracy of our est~mateor any other aspects of this form, includ~ngsug estions for reduc,ing
completion time, to the Chief of Information Management, Railroad Retirement Board, 44 North Rush
Street, Chicago, Illinois 60611-2092.

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