Form AA-104 (08-08) AA-104 (08-08) Application for Canadian Hospital Benefits Under Medicar

Form Approved

OMB No. 3220-0086

United States of America
Railroad R
•Board

APPLICATION FOR CANADIAN HOSPITAL BENEFITS
UNDER MEDICARE - PART A
1. Your Provincial Hospital Insurance Number ............ iI"
2.

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Copy From Your Health Insurance Card
3. Claim Number with Prefix

of Beneficiary (Patient)

4. Sex
D

5.

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

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Male

D Female

DYes - Go to Section 1
D No - Go to Section 2

before period of this claim

6a. Enter an "X" in the appropriate box and the period of service.
D Hospital. ............................................................ iI"
D Nursing Home/Convalescent Hospital.. .................... iI"

Admitted
Discharged
Admitted
Discharged

Month

Day

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Year

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Name of Hospital or Nursing

b. Enter the name and address of the hospital or
nursing home in which you were an inpatient in
the 60-day period before the first day you were
furnished the services covered by this claim.

Full A.ddress (Include City,

...

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...

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ZIP Code)

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Se. vices covered by this claim

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7a. Enter an "X" in the appropriate box and the period of service covered by this
claim.
Admitted
D In-Patient Hospital .............................................. iI"
Discharged
In-Patient Nursing Home/Convalescent Hospital ....... iI"
D Home Health .......... iI"

Enter total number
of visits

7b. Only complete Item 7b if the address is different
from Item 5c above.

..... iI"

Admitted
Discharged
First Visit
Last Visit

Month

Day

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Year

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Name of Hospital or Nursing Home

..... iI"
Full Address (Include City, Province, ZIP Code)

Otherwise, enter an "X" in the box
to indicate the address is the same. ..... iI"O

8.

Descrlu~

the illness or injury for which you

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treatment.

9. Was your illness or injury connected with your employment? .............................. iI"
10a. Were you billed for any of the services furnished? ......................................... iI"
b. How much did you pay? ........................................................................... iI"
AA-104 (08-08) DESTROY PRIOR EDITIONS

= Yes
No
= Yes - Go to Item 10b
No - Go to Item 11

$

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11.

Please verify that you have furnished all information requested by signing and dating this form. You must also
enclose:
• 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
• your receipted bills.
Return this form to:

12.
13.

U.S. Railroad Retirement Board
844 North Rush Street
Chicago, IL 60611-2092

I Date ~ I

Signature of Patient ......... ~
Street Address ............... ~
City and Province ........... ~

Telephone Number

Area Code
Daytime Telephone Number .......... ~

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14.

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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.
a

Signature of Witness ......... ~

Address

............................ ~
~

Area Code

Telephone Number

Daytime Telephone Number ... ~

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b

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Signature of Witness .......... ~

Address ............................. ~
Area Code

Telephone Number

Daytime Telephone Number ... ~

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PAPERWORK REDUCTION ACT AND PRIVACY ACT NOTICES
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 necessa~ to administer the Medicare program. For example, it may be necessary to disclose information
about the Medicare benefi s 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 ofthe 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
ncies may not conduct or sponsor, and
a valid OMB number. If you wish, send
respondents are not required to respond to, a collection of information unless it dis
comments regarding the accuracy of our estimate or any other aspect of this form, including suggestions for reducing
completion time, to Chief of Information Resources Management, Railroad Retirement Board, 844 Rush St, Chicago, Illinois
60611-2092.

AA-I04 (08-08)