Information Collection

Medicare

IC 33882 under ICR 202206-3220-004 · OMB 3220-0082.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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-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-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
AA-8 (01-12) Widow/Widower Application for Medicare Form AA-8 (01-12).pdf	Form and Instruction

IC Title:

Medicare

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 407 42 CFR 406

Information Collection Instruments:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.