Medicare

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3220-0082 can be found here:

Documents and Forms

Document Name Document Type
Form AA-6 (01-12) Medicare Form and Instruction
AA-6 (01-12) Employee Application for Medicare Form AA-6 (01-12).pdf Form and Instruction
AA-7 (01-12) Spouse/Divorced Spouse Application for Medicare Form AA-7 (01-12).pdf Form and Instruction
AA-8 (01-12) Widow/Widower Application for Medicare Form AA-8 (01-12).pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Medicare	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 407 42 CFR 406

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form and Instruction	AA-6 (01-12)	Employee Application for Medicare	Form AA-6 (01-12).pdf	No	Paper Only
Form and Instruction	AA-7 (01-12)	Spouse/Divorced Spouse Application for Medicare	Form AA-7 (01-12).pdf	No	Paper Only
Form and Instruction	AA-8 (01-12)	Widow/Widower Application for Medicare	Form AA-8 (01-12).pdf	No	Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title: RRB-20; Health Insurance and Supplementary Medical Insurance Enrollment and Premium Payment System (Medicare)	FR Citation: 79 FR 58874

Number of Respondents: 240	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	240	240
Annual IC Time Burden (Hours)	32	32
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.