Crosswalk

Revisions to Form CMS R-285 (OMB 0938-0769) Request for Retirement Benefit Information
This form was updated to add “Medicare” to the title of the form. An introduction page has been added to explain who should use this
form, how to submit it, how to get help with completing the form, and how to get information in another format. Section headings A
and B have been added to clearly specify which questions should be completed by the applicant (the top of the form) and which
should be completed by the employer (questions 1-5 and the signature).
Changes
Updated Form

Original Form

Reason for Change

Page 1:

Page 1:

Form title: Medicare
Request for Retirement
Benefit Information

Form title: Request for
Retirement Information

Per Office of Communications’
(OC) plain language suggestion,
the title is being updated to
specify that this request for
retirement benefit information is
a Medicare request.

Added Introduction
page: has been added

to explain who should
use this form, how to
submit it, how to get
help with completing
the form, and how to
get information in
another format.
PRA Disclosure
Statement is on the
introduction page.

No Introduction Page
The is a section for the
employee to complete
their name, SSN,
employer name and
address, and claimant
name and SSN if
different from the
employee’s name.
There is a section for
the employer to
complete that includes
5 questions. There are
no section headings to
clearly identify which
section should be

This form format is being
updated to mirror the format of
other recently updated Medicare
Part A and B enrollment forms.
The applicant should be informed
on who should use the form, how
to submit it, how to get help with
completing the form, and how to
get the form in another format.

Burden
Effect
N/A

completed by the
employee and which
should be completed by
the employer.

Page 2:
Added section headings
to identify which
section should be
completed by the
employee and which

should be completed
by the employer.

PRA Disclousre
Statement is on the
page with the
applicant/employer
questions.
Page 2:
N/A

Page 2:
Section headings added to clearly
identify which section should be
completed by the employee and
which should be completed by
the employer, similar to the CMSL564.

N/A