Form AA-6 (01-03) AA-6 (01-03) Employee Application for Medicare

UNITED STATES OFAMERICA
RAILROAD RETIREMENT BOARD

FORM APPROVED
O.M.B. NO. 3220-0082

DO NOT WRITE IN THIS SPACE
OFFICIALLY FILED
DAY

MONTH

OFFICE
NUMBER

YEAR

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EMPLOYEE APPLICATION
FOR MEDICARE

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APPROVED

DATE CODED

APPLICATION

MONTH

CODED BY

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Identifying Information

Check the information entered by the Railroad Retirement Board (RRB) for items 1 through 8 for accuracy.
* If the information is correct, go to Section 2.
If the information is not correct, cross out the incorrect information and enter the correct information above it.
If the information is missing, fill it in.

*
*

1 1

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1

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RAILROAD EMPLOYEE'S SOCIAL SECURITY NUMBER

'A
PREFIX

EMPLOYEE'S RAILROAD RETIREMENT CLAIM NUMBER (IF ANY)

/ 1
3

YOUR NAME

a

4

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NUMBER

MAILINGADDRESS +

CITY AND STATE +

-

ZIP CODE

b

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5

COUNTY

1 1
4c

a YES

FOREIGN ADDRESS

a NO
TELEPHONE NUMBER

>

YOUR DAYTIME TELEPHONE NUMBER

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YOUR DATE OF BIRTH

6

1 1
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181-

YOURSEX

a

YOUR SURNAME AT BIRTH (IF DIFFERENT FROM ITEM 3)

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DAY

MALE
FEMALE

YEAR

'Go to Section 2
'Go to item 8

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Information About Your Railroad Work And Military Service

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MONTH

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Does your most recent Form BA-6 show that you have
120 or more months of railroad service?

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YES
NO

7

a YES

Do you have 60 or more months of railroad service
after 1995?

Are you still working in the railroad industry?

NO

' a YES
NO
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*
*
*
*
*
*

Go to Section 3
Go to item 10
Go to Section 3
Gotoitemll
Go to item I 3
Gotoitem12
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Form AA-6 (01-03) Destroy Prior Editions

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MONTH

12

Give the date you last worked in the railroad industry.

YEAR

>

Have you ever been in active military service
in the U.S. Army, Navy, Air Force or Marines?
C--------------------------------------

NOTE: Please read the proofs booklet to find out where to get proof of military service. Creditable military service
may be used to determine your eligibility for Medicare.

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Information About Social Security Entitlement
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14

1

151

Have you ever filed an application for
social security benefits?

Social security number of person
on whose record you filed.
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* Go to item 15

NO > Go to Section 4
YES

Did you file for social security benefits based
on your own wage record?
Name of person on whose
record you filed.

17

YES

*

NO

* Go to Section 4
* G o t o i t e m 16

*

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Request for Enrollment In Medicare Medical lnsurance Part B

11
18

In addition to applying for Hospital lnsurance under Medicare Part A, you may also elect to enroll in Medicare Part B.
This plan helps pay for physicians' services and certain other medical expenses not covered by the hospital plan. If
you enroll in this medical plan, you will be required to make premium payments.
DOyou wish to enrol in Medicare Part B?

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Remarks
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This section is to be used for the continuation of answers to other items. Be sure to include the item number at the

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Form AA-6 (01-03) Page 2

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Certification
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Will you have a guardian or other representative
sign this application on your behalf?

(

*

!J YES
!J NO

*
*

Go to "Note" and item 21
Go to item 21

NOTE: If answered "YES" the guardian or other represenfative of fhe applicant must sign fhis applicafion.
Thaf person must also complete and refurn Form AA-5, 'Application for Subsfifufion of Payee."

I know that if I make a false or fraudulent statement in order to qualify for Medicare from the Railroad Retirement Board
(RRB), I am committing a crime which is punishable under Federal law.
I certify that the information I gave to the RRB on this application is true to the best of my knowledge.
I agree to notify the RRB immediately:
If there is a change in my marital status, or
If I change my address.

YOUR SIGNATURE
(First Name, Middle
Initial, Last Name)

DATE

22

*

If this certification is signed by mark ("X) in item 21, two witnesses who know the person signing must sign below, giving
their full addresses and daytime telephone numbers.

a Signature of Witness

Address (Number and Street)

City, State, ZIP Code

1

Daytime Telephone Number
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b Signature of Witness

Address (Number and Street)

City, State, ZIP Code

Daytime Telephone Number

Area Code

Telephone Number

p p

Form AA-6 (01-03) Page 3

How To Return Your Application

~ e f o r eyou return your application, check to make sure that:
EVERY QUESTION THAT APPLIES TO YOU HAS BEEN ANSWERED.

>

YOU HAVE ENTERED "UNKNOWN" IN ANY ANSWER SPACE FOR WHICH YOU WERE
UNABLE TO ANSWERA QUESTION.
YOU HAVE SIGNED AND DATED THE APPLICNION.
YOU HAVE INCLUDED ALL THE NEEDED PROOFS LISTED IN THE LETTER YOU
RECEIVED WITH THIS APPLICATION.

When you received your application, you should also have received a pre-addressed envelope. If you do not
have this envelope, you can use any envelope as long as it is addressed to the RRB office shown on page 5
of this application. IVo matter which envelope you use, you must put the correct postage on the envelope.
Be careful to provide enough postage, because your application and the accompanying forms may weigh more
than a standard letter. The U.S. Postal Service will not deliver your application unless it has the correct postage.

Make one final check before you seal the envelope to ensure that the following are enclosed:
NEEDED PROOFS
THE APPLICATION FORM ITSELF
ADDITIONAL FORMS YOU WERE ASKED TO COMPLETE

/--

\

Note: Make no entries on page 5, which is the receipt for your claim. After the RRB receives your
application, they will complete the blanks on the receipt and send it back to you. When you receive it,
you will know that the RRB has received your application and has started the work needed to determine
if you are entitled to Medicare. I f you do not receive the receipt within two weeks after you filed this
application, please contact us so we can find out what is causing the delay.

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Form AA-6 (01-03) Page 4

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RAILROAD RETIREMENT BOARD CLAIM NUMBER

APPLICANT'S NAME

DATE CLAIM RECEIVED

Your application for Medicare has been received and will be processed as quickly as possible. If you
change your address, or if your marital status changes, you or your representative should report the
change. Always give us your claim number when writing or calling about your claim. If you have any
questions about your claim, we will be glad to help you. If you need to personally visit one of our field
offices, please call for an appointment. You will not be refused service if you do not have an appointment,
but our staff can serve you better when an appointment is made. Most offices are open to the public from
9:00 AM to 3:30 PM, Monday through Friday.

Change of Address - If you chauge your mailing address-to avoid delay in receipt of RRB
correspondence, you should also file a regular change of address notice with
your post office.
Change of Marital Status

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If you remarry or become divorced or your marriage ends due to the death of
your spouse.

You can make your reports either by telephone, mail, or in person, whichever you prefer. When a change
occurs after you are enrolled for Medicare, you or your representative should report the change at once.
To report any of the above changes, contact:

Telephone Number:

If for some reason you cannot contact that office, you should contact:

)

U S RAILROAD RETIREMENT BOARD

844 N RUSH ST
CHICAGO IL 60611-2092
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Form AA-6 (01-03) Page 5

Paperwork Reduction Act and Privacy Act Notices
This notice is given under the Papework Reduction Act of
1995 and the Privacy Act of 1974. The Privacy Act
requires that the Railroad Retirement Board (RRB) tell
you the following whenever we ask you for information.
1) The law which allows us to ask for the information;
2) whether that law requires you to give us that
information and what, if anything, might happen to you if
you do not give it to us;

3) the reason why the information is requested; and
4) the persons, organizations, and agencies to which we
may release the information without your permission.

The RRB is authorized to collect the information on this
form under sections 7(b) and 7(d) of the Railroad
Retirement Act and sections 226, 1836, and 1840 of
the Social Security Act, as amended. The information
on this form is needed to enable the RRB to
determine your eligibility to monthly benefits and
entitlement to hospital and/or medical insurance
coverage. While you do not have to furnish the
information requested on this form, no hospital or medical
insurance can be provided until an application has been
received. Failure to provide all or part of the information
requested could prevent an accurate and timely decision
on your claim and could result in the loss of hospital or
medical insurance.
Although the information you furnish on this form is
almost never used for any other purpose than stated
above, there is a possibility that for the administration of
the Railroad Retirement, Social Security, and the Centers
for Medicare & Medicaid Services programs,
information may be disclosed to another person or to
another government agency as follows:
1) Beneficiary identification, enrollment status and
premium deductions information may be released to the
Social Security Administration and the Centers for
Medicare & Medicaid Services to correlate action with
the administration of Title II and Title XVlll (MEDICARE)
of the Social Security Act.
2) Beneficiary identification may be disclosed to third
party contacts to determine if incapacity of the
beneficiary or potential beneficiary to understand or use
benefits exists, and to determine the suitability of a
proposed representative payee.
3) Jurisdictional clearance, premium rate, coverage
electjon, paid-thru date, and amounts of payments in
arrears may be released to the Social Security
Administration and the Centers for Medicare &
Medicaid Services to assist in administering Title XVlll
of the Social Security Act.

'orm AA-6 (01-03) Page 6

4) The last address information may be disclosed to
the Department of Health and Human Services in
conjunction with the Parent Locator Service.

5) Beneficiary identification, entitlement data and rate
information may be referred to the Department of State
and embassy officials to aid in the development of
applications, supporting evidence and the continued
eligibility of beneficiaries and potential beneficiaries living
abroad.

6) Records may be released to the General Accounting
Office for auditing purposes and for collection of debts
arising from overpayments under Title XVlll of the Social
Security Act, as amended.

7) Disclosure may be made to a congressional office from
the record of an individual in response to an inquiry from the
congressional office made at the request of that individual.
8) Pursuant to a request from an employer covered by
the Railroad Retirement Act or the Railroad
Unemployment Insurance Act, information regarding the
RRB's determination of Medicare entitlement, entitlement
data and present address may be released to the
requesting employer for the purposes of determining
entitlement to and rates of supplemental benefits payable
under private employer welfare benefit plans.
We estimate this form takes an average of 8 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 aspect of this
form, including suggestions for reducing completion time,
to Chief of lnformation Resources Management, Railroad
Retirement Board, 844 North Rush Street, Chicago,
Illinois 60611-2092.

Computer Matching and Privacy Protection Act Notice
The Computer Matching and Privacy Protection Act of
1988 requires the Railroad Retirement Board (RRB) to
advise you that information you have provided may be
used, without your consent, in automated matching
programs. These matching programs are a computer
comparison of RRB records with records kept by other
Federal, state, or local governmental agencies.
lnformation from these matching programs can be used to
establish or verify a person's eligibility for Federally
funded or administered benefit programs and for
repayment of payments or delinquent debts under these
programs.