Cms-18f5 Application For Hospital Insurance

Form Approved
OMB No. 0938-0251

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

(Do Not Write in this space)

APPLICATION FOR HOSPITAL INSURANCE
(This application form may also be used to
enroll in Supplementary Medical Insurance)

I apply for entitlement to Medicare’s hospital insurance under part A of title XVIII of the Social Security Act,
as presently amended, and for any cash benefits to which I may be entitled under title II of that Act.

1.

(First name, Middle initial, Last name)
(a) Print your name
(b) Enter your name at birth if
different from 1 (a)

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2.
3.

Enter your Social Security Number

Male

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(c) Enter your sex (check one)

Female

———/——/————

(a) Enter your date of birth (month, day, year)
(b) Enter name of State or foreign country where you were born
If you have already submitted a public or religious record of
your birth made before you were age 5, go on to item 4)
No

Unknown

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No

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Unknown

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■
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No

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(a) Have you (or has someone on your behalf) ever filed an application for
social security benefits, a period of disability under social security
supplemental security income, or hospital or medical insurance under
Medicare?

Yes

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(d) Was a religious record of your birth made before you were age 5?

Yes

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4.

(c) Was a public record of your birth made before you were age 5?

Yes

If “Yes” answer
(b) and (c).

If “No” go on
to item 5.

(b) Enter name of person on whose social security record you filed
other application

If “No” go on
to item 6.

From: (Month, Year) To: (Month, Year)

Yes

No

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Yes

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(c) Have you ever been (or will you be) eligible for a monthly benefit
from a military or civilian Federal agency? (Include Veterans Administration
benefits only if you waived military retirement pay)
6. Did you work in the railroad industry any time on or after January 1,
1937?
Form CMS-18F5 (02/91) Page 1

If “Yes” answer
(b) and (c).

No

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(b) Enter dates of service

Yes

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(a) Were you in the active military or naval service (including
Reserve or National Guard active duty or active duty for training)
after September 7, 1939?

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5.

———/——/————
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(c) Enter Social Security Number of person named in (b), (If unknown,
so indicate)

No
(Over)

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Yes

No

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No

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No

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(a) Have you ever engaged in work that was covered under the social
security system of a country other than the United States?

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7.

No

(b) If “Yes”, list the country(ies).

8.

(a) How much were your total earnings last year?
If none, write “None”
(b) How much do you expect your total earnings to be this year?
If none, write “None”

Earnings
$

Are you a resident of the United States?
To reside in a place means to make a home there.

Yes

(a) Are you a citizen of the United States?
If “Yes”, go on to item 11. If “No”, answer (b) and (c) below.

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Yes

(b) Are you lawfully admitted for permanent residence in the
United States?

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10.

$

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9.

Earnings

Yes

(c) Enter below the information requested about your place of residence in the last 5 years:
DATE RESIDENCE DATE RESIDENCE
ADDRESS AT WHICH YOU RESIDED IN THE LAST 5 YEARS
BEGAN
ENDED
(Begin with the most recent address. Show actual date residence began even if that
is prior to the last 5 years)

Month

Day

Year

Month

Day

(If you need more space, use the “Remarks” space on the third page or another sheet of paper)

YOUR
CURRENT
MARRIAGE

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Are you currently married?

Yes

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11.

No

If “Yes”, give the following information about your current
marriage. If “No”, go on to item 12.
To whom married (Enter your wife’s maiden name or your
husband’s name)
Spouse’s date of birth (or age)

When (Month, Day, Year)

Spouse’s Social Security Number
(If none or unknown, so indicate)

———/——/————
12.

If you had a previous marriage and your spouse died, OR if you had a previous marriage which lasted 10 or more
years, give the following information. If you had no previous marriage(s), enter “NONE.”

YOUR
PREVIOUS
MARRIAGE

To whom married (Enter your wife’s maiden name or your
husband’s name)
Spouse’s date of birth (or age)

When (Month, Day, Year)

Spouse’s Social Security Number
(If none or unknown, so indicate)

———/——/————
If spouse deceased, give date of death
(Use “Remarks” space on the page 3 for information about any other marriages.)
Form CMS-18F5 (02/91) Page 2

Year

No

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Yes

No

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Yes

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No

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Yes

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No

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Yes

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(d) Were either you or your spouse an employee of the Federal Government
after February 15,1965?

Yes

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(c) Are you and your spouse barred from coverage under the above Act
because your Federal employment, or your spouse's was not long
enough?
If "Yes," omit (d) and explain in "Remarks" below. If "No," answer (d).

No

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(b) Are you or your spouse now covered under a medical insurance
plan provided by the Federal Employees Health Benefits Act of 1959?
If "Yes," omit (c) and (d). If "No," answer (c).

Yes

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(a) Were you or your spouse a civilian employee of the Federal Government
after June 1960?
If "Yes," answer (b). If "No," omit (b), (c), and (d).

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14.

Is or was your spouse a railroad worker, railroad retirement pensioner, or a
railroad retirement annuitant?

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13.

No

Remarks:

15.

If you are found to be otherwise ineligible for hospital insurance under
Medicare, do you wish to enroll for hospital insurance on a monthly premium
basis (in addition to the monthly premium for supplementary
medical insurance)?
If "Yes," you MUST also sign up for medical insurance.

INFORMATION ON MEDICAL INSURANCE UNDER MEDICARE
Medical insurance under Medicare helps pay your doctor bills. It also helps pay for a number of other medical items and
services not covered under the hospital insurance part of Medicare.
If you sign up for medical insurance, you must pay a premium for each month you have this protection. If you get monthly
social security, railroad retirement, or civil service benefits, your premium will be deducted from your benefit check, if you get
none of these benefits, you will be notified how to pay your premium.
The Federal Government contributes to the cost of your insurance. The amount of your premium and the Government's
payment are based on the cost of services covered by medical insurance. The Government also makes additional payments
when necessary to meet the full cost of the program. (Currently, the Government pays about two-thirds of the cost of this
program.) You will get advance notice if there is any change in your premium amount.
If you have questions or would like a leaflet on medical insurance, call any Social Security office.

SEE OTHER SIDE TO SIGN UP FOR MEDICAL INSURANCE

Form CMS-18F5 (02/91) Page 3

(Over)

If you become entitled to hospital insurance as a result of this application, you will be enrolled for medical insurance
automatically unless you indicate below that you do not want this protection. If you decline to enroll now, you can get medical
insurance protection later only if you sign up for it during specified enrollment periods. Your protection may then be delayed
and you may have to pay a higher premium when you decide to sign up.
The date your medical insurance begins and the amount of the premium you must pay depend on the month you file this
application with the Social Security Administration. Any social security office will be glad to explain the rules regarding
enrollment to you.

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Yes

(Enrollees for premium hospital insurance must simultaneously enroll
for medical insurance.)

Are you or your spouse receiving an annuity under the
Federal Civil Service Retirement Act or other law administered by the
Office of Personnel Management?

No

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Currently Enrolled

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Yes

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No

Yes

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17.

DO YOU WISH TO ENROLL FOR SUPPLEMENTARY MEDICAL
INSURANCE?
If "Yes," answer question 17.

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16.

No

Your No.
If "Yes," enter Civil Service annuity number here. Include the prefix "CSA" for
annuitant, "CSF" for survivor.

Spouse's No.

If you entered your spouse's number, is he (she) enrolled for supplementary
medical insurance under social security?

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I know that anyone who makes or causes to be made a false statement or representation of material fact in an
application or for use in determining a right to payment under the Social Security Act commits a crime punishable
under Federal law by fine, imprisonment or both. I affirm that all information I have given in this document is true.
Date (Month, Day, Year)

SIGNATURE OF APPLICANT
Signature (First name, Middle initial, Last name) Write in Ink
SIGN
HERE

Telephone Number(s) at which you
may be contacted during the day

Mailing address (Number and street, Apt. No., P.O. Box, or Rural Route)

City and State

ZIP Code

Enter Name of County (if any) in which you now
live

Witnesses are required ONLY if this application has been signed by mark (X) above. If signed by mark (X), two witnesses to
the signing who know the applicant must sign below, giving their full addresses.
1. Signature of Witness

2. Signature of Witness

Address (Number and street, City, State, and ZIP Code)

Address (Number and street, City, State, and ZIP Code)

Form CMS-18F5 (02/91) Page 4

A REMINDER TO APPLICANTS FOR THE SOCIAL SECURITY HOSPITAL INSURANCE

NAME OF PERSON TO CONTACT ABOUT YOUR CLAIM

SSA OFFICE

DATE

TELEPHONE NO.

RECEIPT FOR YOUR CLAIM
Your application for the hospital insurance has been received and
will be processed as quickly as possible.

You should hear from us within
days after you have given
us all the information we requested. Some claims may take longer
if additional information is needed.
CLAIMANT

ln the meantime, if you change your mailing address, you should
report the change.
Always give us your claim number when writing or telephoning
about your claim.
If you have any questions about your claim, we will be glad to
help you.
SOCIAL SECURITY CLAIM NUMBER

COLLECTION AND USE OF INFORMATION FROM YOUR APPLICATION — PRIVACY ACT NOTICE

PRIVACY ACT NOTICE: The Social Security Administration
(SSA) is authorized to collect the information on this form
under sections 226 and 1818 of the Social Security Act, as
amended (42 U.S.C. 426 and 1395-17) and section 103 of
Public Law 89-97. The information on this form is needed to
enable social security and the Centers for Medicare &
Medicaid Services (CMS) to determine if you and your
dependents may be entitled to hospital and/or medical
insurance coverage and/or monthly benefits. While you do not
have to furnish the information requested on this form to social
security, no benefits or hospital or medical insurance can be
provided until an application has been received by a social
security office. Failure to provide all or part of the information
requested could prevent an accurate and timely decision on
your claim or your dependent's claim, and could result in the
loss of some benefits 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 social security or CMS
programs or for the administration of programs requiring
coordination with SSA or CMS information may be disclosed to
another person or to another governmental agency as follows:
1) to enable a third party or an agency to assist social security
or CMS in establishing rights to social security benefits and/or
hospital or medical insurance coverage; 2) to comply with
Federal laws requiring the release of information from social
security and CMS records (e.g., to the General Accounting
Office and the Veterans Administration); and 3) to facilitate
statistical research and audit activities necessary to assure the
integrity and improvement of the social security and CMS
programs (e.g., to the Bureau of the Census and private
concerns under contract to social security and CMS).

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays
a valid 0MB control number. The valid 0MB control number for this information collection is 0938-0251. The time required to complete
this information collection is estimated to average 15 minutes per response, including the time to review instructions, search existing
data resources, gather the data needed, and complete and review the information collection. It you have any comments concerning the
accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, Attn: PRA Reports Clearance Officer,
7500 Security Boulevard, Baltimore, Maryland 21244-1850.

Form CMS-18F5 (02/91) Page 5