Form AA-104 (01-02) AA-104 (01-02) Application for Canadian Hospital Benefits Under Medicar

United States of America
Railroad Retirement Board

Form Approved
OMB NO. 3220-0086

APPLICATION FOR CANADIAN HOSPITAL BENEFITS
UNDER MEDICARE PART A

-

1. Your Provincial Hospital Insurance Number

p
2.

3.

Name of Beneficiary (Patient)

Claim Number with Prefix

4. Sex
Male

5.a.

b.

Were you an inpatient in a hospital, nursing home, or convalescent
hospital in the 60-day period before the first day you were furnished the
services covered by this claim?

Yes - Go to Item 5b
No - GO to ltem 6
Month

Name and Address of Hospital or
Home

Female

Day

Year

Admitted
Hospital
Discharged
Nursing Home or
Convalescent
Hos~ital

-

-

Admitted
Discharged
-

-

Name and address of hospital or agency furnishing the service covered by this claim. If same as above, enter
"Same."

7. Type of service and period in which furnished.

In-Patient Hospital .................................................
In-Patient IVursing Home or
Convalescent Hospital...........................................

Admitted

Home Health . . . .

First Visit

Number of visits

Discharged

Last Visit

8.

I

Describe the illness or injury for which you received treatment.

9. Was your illness or injury connected with your employment?
10a. Were you billed for any of the services furnished?

Yes

1

Yes

No

G to item 10b 7

No - Go to ltem 11
b. How much did you pay?
I

I

AA-104 (01-02) DESTROY PRIOR EDITIONS

$

I

11.

Please verify that you have furnished all information requested by signing and dating this form. You must also
enclose:
I

your doctor's certification that the service was medically necessary (certification is not required if any part of the
charges for such services is payable under a provincial program), and

1

your receipted bills.

Return this form to:

12.

Signature of Patient

13.

Street Address

1

City and Province

U.S. Railroad Retirement Board
844 North Rush Street
Date

1

I

Area Code

Telephone Number

Daytime Telephone Number
I

14.

I

I

I

I

I

I

I

I

I

I

If this form is signed by mark ( " X ) in Item 12, two witnesses who know the person signing must sign below giving
their full addresses and daytime telephone numbers.

/ I
a

-

Signature of Witness

1

I

Address

Area Code

Telephone Number

Area Code

Telephone Number

Daytime Telephone Number

I 1
b

Signature of Witness

I

Address

I

Daytime Telephone Number
PAPERWORK REDUCTION AND PRIVACY ACT NOTICE

We are authorized to ask you for information needed in the administration of the Medicare program. Authority to collect
information is in Sections 7(b) and 7(d) of the Railroad Retirement Act (RRA).
The information we obtain on your Medicare claim is used to identify you and to determine your eligibility. It is also used to
decide if the services and supplies you received are covered by Medicare and to make proper payment.
The information may also be given to other providers of services, carriers, intermediaries, medical review boards, and other
organizations as necessary to administer the Medicare program. For example, it may be necessary to disclose information
about the Medicare benefits you have used to a hospital or doctor.
With one exception, which is discussed below, there are no penalties under railroad retirement law for refusing to supply
information. However, failure to furnish the amount charged would prevent payment of the claim. Failure to furnish any other
information, such as name or claim number, would delay payment of the claim.
It is mandatory that you tell us if you are being treated for a work-related injury so we can determine whether worker's
compensation will pay for the treatment. Section 13(a) of the RRA provides criminal penalties for withholding this information.
We estimate this form takes an average of 10 minutes per response to complete, including the time for reviewing the
instructions, getting the needed data, and reviewing the completed form. Federal agencies may not conduct or sponsor, and
respondents are not required to respond to, a collection of information unless it displays a valid OMB number. If you wish,
send comments regarding the accuracy of our estimate or any other aspects of this form, including suggestions for reducing
completion time, to Chief of Information Management, Railroad Retirement Board, 844 Rush St, Chicago, Illinois 60611-2092.