CMS-R-285 Request for Retirement Benefit Information

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

Form Approved
OMB No. 0938-0769
Expires: xx/xx

Medicare Request for Retirement Benefit Information
Use this form to request a Medicare Part A (Hospital Insurance) premium reduction based on your employment by a
state or local government.

How to submit this form
Mail, fax, or take your completed form to your local Social Security office. Find an office near you at
SSA.gov/locator.

Get help with this form
• Phone: Call Social Security at 1-800-772-1213. TTY users can call 1-800-325-0778.
• En Español: Llame a SSA gratis al 1-800-772-1213 y oprima el 2 si desea el servicio en español y espere a que le
atienda un agente.
• In-person: Visit your local Social Security office for in-person help. Find an office near you at SSA.gov/locator.

Get information in another format
You have the right to get Medicare information in an accessible format, like large print, braille, or audio. You
also have the right to file a complaint if you feel you’ve been discriminated against. Visit Medicare.gov/about-us/
accessibility-nondiscrimination-notice, or call 1-800-MEDICARE (1-800-633-4227) for more information. TTY users
can call 1-877-486-2048.

PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information
unless it displays a valid OMB control number. The valid OMB control number for this information is 0938-0769. 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. If you have comments concerning the accuracy of the
time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer,
Mail Stop C4-26-05, Baltimore, MD 21244-1850.
Form CMS-R285

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Form Approved
OMB No. 0938-0769
Expires: xx/xx

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

Medicare Request for Retirement Benefit Information
You complete Section A of this form, then ask your employer to fill out Section B.
Section A: To be completed by the person requesting a Medicare Part A premium reduction
1. Employee name

2. Employee Social Security Number

3. Employer name

4. Employer address

City

State

ZIP code

5. Claimant name (if different from the employee’s name)

6. Claimant Social Security Number

Section B: To be completed by employer
We need the information listed below in connection with _________________________________________________
(claimant’s name)

1. Is the claimant receiving retirement payments based on his/her own state or local government employment?........................

Yes

No

2. Is the claimant the spouse, divorced spouse, widow or widower of a person who is receiving (or did receive) .........................
retirement payments based on his/her own state or local government employment?

Yes

No

4. Has the pension plan or former employer subsidized the claimant’s Medicare Part A premium in whole or in ........................
part for any month during the past 7 years?

Yes

No

5. If the claimant is found to be eligible for the reduced Medicare Part A premium, will his/her retirement ................................
payments be adjusted or recalculated?

Yes

No

3. How long did the claimant (or spouse) work for the state or local government employer?
Beginning date (mm/yyyy)

Last date of employment (mm/yyyy)

I certify that the statements given above are true. I know that anyone who makes a false statement or representation of a material fact for use
in determining a right to payment under the Social Security Act commits a crime punishable under Federal law.
Signature of agency official

Title of agency official

Phone number

Date signed (mm/dd/yyyy)

Form CMS-R285

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