AA-7 (01-03) Spouse/Divorced Spouse Application for Medicare

UNITED STATES OF AMERICA
RAILROAD RETIREMENT BOARD

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

Do Not Write in This Space
OFFICIALLY FILED
OFFICE NUMBER

SpouselDivorced Spouse
Application for
Medicare

APPROVED

.....................................................
DATE CODED
APPLICATION NUMBER

CODED BY

Identifying Information
Check the information entered by the Railroad Retirement Board (RRB) for items 1 through 10 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 Railroad Employee's Social Security Number

2 Employee's Railroad Retirement Claim Number (if any)

3 Employee's Name -+

1

4 Your Name

-

5 a Mailing AddressCity and State
ZIP Code
b County
6

5c Foreign Address

Your Daytime Telephone Number

8 Your Sex

-

MALE

YES

D NO

7 Your Date of Birth

* Go to item 10
* Go to item 9

9 Your Surname at Birth (if different from item 4)

-

FEMALE

10 Your Social Security Number

-

Information about the Employee's Railroad Work and Military Service
11 Has anyone ever filed an application for monthly benefits or
Medicare under the Railroad Retirement Act on this
account number?

D

*

YES

a NO

UNKNOWN

*
*
*

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Form AA-7 (01-03) Destroy Prior Editions

a YES
a NO

*

12 Is the employee still working in the railroad industry?

-a
-a
-a
-

*
*

MONTH

13 Give the date the employee last worked in the railroad industry.

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14 Is the employee age 62 or older in the month you attain age 65?
15 Does the employee have 120 or more months of railroad service?

16 Does the employee have 360 or more months of railroad service?

(

NO

YES
NO
YES

*

Q NO

I

l

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-

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O YES
1
0 NO
--.-----------------------------------1

/

/

(

l

*I

~u.s.
Army, Navy, Air Force or Marines?
.........................................................................................................................................

I

*
*
*
*
*
*
*
*

YES

[7 NO

1 18 1 Was the employee ever in active military service in the
1

I

0 YES

Did the employee have 60 or more months of railroad service
after 1995?

(

YEAR

I

a

Go to item I 4
GOto item 13

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.

)

\

Applicant's Marital History

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19 Enter an " X in the box which shows your current marital status to
the railroad employee.

Q Married

a Divorced

*

20 Were you ever married before or since your marriage to the railroad
employee? Note: Answer "NOJ'ifyou were only remarried to the
railroad employee.

0 YES *
O
*

Go to item 21
Go to item 22

Enter the following information about each of your marriages beginning with your most recent one
(do not include marriage to the railroad employee).
Marriage Began
Date

Place (city and state)

Name of Spouse

Marriage Ended
How
(check one)

CI Death
Divorce

CI Annulment
CI Death
CI Divorce
CI Annulment

Form AA-7 (01-03) Page 2

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Date

1

Place (city and state)

-I 1
1

Information about Social Security Entitlement
22 Have you ever filed an application for social security benefits?
23 Did you file for social security benefits based on your own wage
record?

~

a YES
a NO
a YES
=- a NO

*
*

Go to item 23
Go to Section 5

*

Go to Section 5
Go to item 24

*

24 Name of person on whose record you filed.

25 Social security number of person on whose record you filed.

M

Request for Enrollment in Medicare Medical lnsurance Part B
In addition to applying for Hospital Insurance 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 prerniuni payments.
26 Do you wish to enroll in Medicare Part B ?

*

a YES
O N 0

Remarks
27 This section is to be used for the continuation of answers to other items. Be sure to include the item
number at the beginning of the answer you wish to continue. You may also use this space to enter
any additional information that you feel may be important to include.

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Form AA-7 (01-03) Page 3

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

*

a

YES
NO

*
*

Go to "Note" and item 29
Go to item 29

Note: If answered "YES," the guardian or other representative of the applicant must sign this
application. That person must also complete and return Form AA-5, "Application for
( Substitution of Payee. "

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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

t

30 If this certificate is signed by mark ("X) in item 29, 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

~a~tim
Telephone
e
Number

Telephone Number

b Signature of Witness

Address (Number and Street)

City, State, ZIP Code

1 /

Daytime Telephone Number

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Form AA-7 (01-03) Page 4

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1
Telephone Number

How to Return Your Application

Before you return your application, check to make sure that:

EVERY QUESTION THAT APPLIES TO YOU HAS BEEN AIVSWERED.
YOU HAVE ENTERED "UNKNOWN" IN ANY AIVSWER SPACE FOR WHICH YOU WERE
LINABLE TO ANSWER A QLIESTION.
YOU HAVE SlGhlED AhlD DATED THE APPLICATION.
YOLl HAVE INCLUDED ALL THE NEEDED PROOFS LISTED IN THE LETTER YOU
RECEIVED WITH THIS APPLICA-TION.

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 6 of
this application. No 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

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THE APPI-ICA-l7ON FORM ITSELF
ADDITIONAL FORMS YOU WERE ASKED TO COMPLETE

Note: Make no entries on page 6, 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. If you do not receive the receipt within twi 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-7 (01-03) Page 5

EMPLOYEE'S NAME

1

APPLICANT'S NAME

RAILROAD RETIREMENT BOARD CLAIM NUMBER DATE CLAIM RECEIVED

XXX-XXYour 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 AIM to 3:30 PM, Monday through Friday.

Change of Address

-

If you change 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 - 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.

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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-7 (01-03) Page 6

Paperwork Reduction Act and Privacy Act Notices
This notice is given under the Paperwork 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
election, 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.

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 ofour 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.

Form AA-7 (01-03) Page