Application for Part A (Hospital Insurance)

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Application for Medicare Part A (Hospital Insurance)
and Medicare Part B (Medical Insurance) for People
with End-Stage Renal Disease
Use this application to apply for Medicare no matter how old you are if you have End-Stage Renal Disease
(ESRD) and all of these apply:
• Your kidneys no longer work
• You need regular dialysis or have had a kidney transplant
Get more information about Medicare for people with ESRD at Medicare.gov/basics/end-stage-renaldisease.

You must submit evidence to show you have ESRD
You’ll need to submit evidence with your application to show you’ve been diagnosed with End-Stage
Renal Disease (ESRD). Your provider needs to complete form CMS-2728 End-Stage Renal Disease Medical
Evidence Report Medicare Entitlement and/or Patient Registration. Submit the completed form with your
application. Download the form at CMS.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS2728.pdf.

How to submit this application
Send your completed and signed application and form CMS-2728 from your provider to your local Social
Security office by fax or mail. Visit SSA.gov/locator to get their contact information.

Get help with this form
• Phone: Call Social Security at 1-800-772-1213. TTY users 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.
• For an office near you visit SSA.gov/locator.
• State Health Insurance Assistance Program (SHIP): Visit shiphelp.org to get free, personalized, and
unbiased health insurance counseling from your local SHIP.

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.

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Form Approved
OMB No. 0938-0080
Expires: XX/XXXX

U.S. Department of Health and Human Services
Centers for Medicare & Medicaid Services

Application for Medicare Part A (Hospital Insurance) and Medicare Part B
(Medical Insurance) for People with End-Stage Renal Disease
Section 1: Basic information
1. Social Security Number (SSN) or your Medicare Number, if you have one
SSN:

Or, Medicare Number:

2. First name

Middle name

Last name

Suffix

3. Name at birth if different
4. Sex
Male

5. Date of birth (mm/dd/yyyy)

6. State or country of birth (no abbreviations)

Female

7. Home address (leave blank if you don’t have one.)
City

State

ZIP code

State

ZIP code

8. Mailing address (if different from your home address)
City
9. Phone number

10. Email address (optional)

Section 2: Earnings and work history
1. How much were your total earnings last year? Enter the total amount of your W2 wages and net earnings.
If none, write “none.”
2. How much do you expect your total earnings to be this year? If none, write “none.”
3. Did you or your spouse (or former spouse) work in the railroad industry for 5 years or more?..........
If no, skip to Section 3.
4. Are you a dependent child using your parent’s work history or Social Security/
Railroad Retirement Board insured status to qualify for ESRD benefits?...........................................................
If yes, complete the following:

Yes

No

Yes

No

Mother’s name
Date of birth (mm/dd/yyyy)

SSN

Railroad Retirement Board (RRB) Number

SSN

Railroad Retirement Board (RRB) Number

Father’s name
Date of birth (mm/dd/yyyy)

5. Have either of your parents worked in the railroad industry for 5 years or more?....................................

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Yes

No

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Section 3: Citizenship
1. Select the citizenship or immigration status that best describes you:
U.S. Citizen or National: I am a citizen or national of the United States. (If selected, skip to Section 4.)
Lawful Permanent Resident: I am an alien lawfully admitted for permanent residence under the Immigration
and Nationality Act.
Cuban/Haitian Entrant: I have been granted status as a Cuban or Haitian entrant.
Compact of Free Association Resident: I lawfully reside in the United States under a Compact of Free
Association (Marshall Islands, Micronesia, or Palau).
Other: I do not meet any of the above categories. (If you select this status, you may not be eligible for
Medicare under current federal law.)
If you selected Lawful Permanent Resident, Cuban/Haitian Entrant, or Compact of Free Association Resident,
complete items 2–7 below:
2. Alien Registration Number (A-Number), if issued:
3. When were you granted your immigration or citizenship status? (mm/dd/yyyy)

4. Are you currently a resident of the U.S.?....................................................................................................................

Yes

No

Yes

No

5. When did you become a resident of the U.S.? (mm/dd/yyyy)

6. Have you resided in the U.S. without a break for the past 5 years?.................................................................

7. List the addresses where you lived for the last 5 years and the dates you lived there. If you need more space,
add the information to the remarks space in Section 7.
Started living there
Stopped living there
Address
(mm/yyyy)
(mm/yyyy)

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Section 4: Marital status
Note: Complete this section only if you’re using your spouse or former spouse’s work record or Social
Security/Railroad Retirement Board insured status to qualify for Medicare.

1. Are you married?...................................................................................................................................................................

Yes

2. Spouse’s first name

Suffix

Middle name

3. Spouse’s date of birth (mm/dd/yyyy)

Last name

No

4. Spouse’s Social Security Number (SSN)

5. Date of marriage (mm/dd/yyyy)
6. If you aren’t married now, did you have a former marriage that lasted 10 or more years or
ended in death? (If no, go to Section 5.).........................................................................................................................

Yes

7. Former spouse’s first name

Suffix

Middle name

Last name

8. Former spouse’s date of birth (mm/dd/yyyy)

9. Former spouse’s Social Security Number (SSN)

10. Date of former marriage (mm/dd/yyyy)

11. Date former marriage ended (mm/dd/yyyy)

No

12. Date of former spouse’s death, if deceased (mm/dd/yyyy)

13. Did you have another marriage that lasted 10 years or ended in death?.....................................................

Yes

No

If you need more space to add another former spouse’s name, date of birth, Social Security Number, start and
end dates of the marriage, or former spouse’s date of death, add the information Section 7.

Section 5: Medical history
1. Have you received regularly scheduled dialysis? ..................................................................................................... Yes
No
(If no, go to item 5.)
2. When did dialysis begin? (mm/dd/yyyy) 3. Has dialysis ended?
4. When did dialysis end? (mm/dd/yyyy)
(If no, go to item 5.)
Yes

No

5. Have you participated in (or do you expect to participate in) a self-dialysis training program? ........
(If no, go to item 7.)
6. When did you start or when do you plan to start participation in a self-dialysis training program?
(mm/dd/yyyy)

Yes

No

7. Have you received a kidney transplant?......................................................................................................................
(If no, go to item 9.)
8. Enter date(s) of transplant(s) (mm/dd/yyyy)

Yes

No

Yes

No

9. Were you in the hospital for related procedures the month before you got the
kidney transplant? ...................................................................................................................................................................
(If no, go to Section 6.)
10. Enter date(s) of hospitalization (mm/dd/yyyy)

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Section 6: Enrollment in Medicare Part B
1. Do you want to sign up for Medicare Part B? (You pay a monthly premium for Part B.).........................
If no, go to Section 8.

Yes

No

2. If your application is processed within 5 months after the first month in which you meet the requirements for
Medicare, your coverage will start that first month.
If your application is processed more than 5 months after the first month in which you meet the requirements,
you can choose one of the following for your first month of coverage. (Please check one.)
The earliest possible month (you must pay all premiums for any past months of coverage)
OR
The month this application is filed
OR
The month this application is processed
Get more information about Medicare coverage start and end dates for people with ESRD at
Medicare.gov/basics/end-stage-renal-disease.
Note: Medicare offers a benefit that helps you pay for your immunosuppressive drugs beyond 36 months. Visit
Medicare.gov/basics/end-stage-renal-disease for more information.

Section 7: Remarks
Use the space below if you need more room to answer questions in Section 3 or Section 4.

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Section 8: Signature(s)
1. If you’re completing this application for someone else, what’s your name and your relationship to the person
applying?

By signing this application, I understand that the information I entered will be used to process my application for
Medicare. I understand that if I intentionally provide false information on this form, it is a crime punishable under
Federal law by fine, imprisonment, or both. I declare under penalty of perjury that the information I entered is
true and correct to the best of my knowledge.
2. Written signature (Do not print)

3. Date signed (mm/dd/yyyy)

If this form has been signed by mark (X), a witness who knows the person applying must also sign below:
4. Name of witness (first and last name)
5. Signature of witness

6. Date signed (mm/dd/yyyy)

I know that anyone who makes a false statement in an application or for use determining a right to
payment under the Social Security Act commits a Federal crime punishable by fine, imprisonment or
both. I affirm that all information given in this document is true.
7. Signature of applicant

8. Date signed (mm/dd/yyyy)

9. Printed name of witness

10. Date signed (mm/dd/yyyy)

How to submit this application
Send your completed and signed application and form CMS-2728 from your provider to your local Social
Security office by fax or mail. Visit SSA.gov/locator to get their contact information.

You must submit evidence to show you have ESRD
You’ll need to submit evidence with your application to show you’ve been diagnosed with End-Stage
Renal Disease (ESRD). Your provider needs to complete form CMS-2728-End-Stage Renal Disease Medical
Evidence Report Medicare Entitlement and/or Patient Registration. Submit the completed form with your
application. Download the form at CMS.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS2728.pdf.

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Privacy Act Statement
Sections 226A and 1872 of the Social Security Act, as amended, allow SSA to collect this information.
Furnishing this information is voluntary. However, failing to provide all or part of the information may prevent
an accurate and timely decision on any claim filed for medical insurance and/or hospital insurance.
We will use the information you provide to determine your eligibility for benefits. We may also share the
information for the following purposes, called routine uses: 1) To Federal, State, or local agencies (or agents
on their behalf) for administering income maintenance or health maintenance programs (including programs
under the Social Security Act). Such disclosure includes, but are not limited to, release of information
to: Railroad Retirement Board for administering provision of the Railroad Retirement Act relating to
railroad employment; for administering the Railroad Unemployment Insurance Act and for administering
provisions of the Social Security Act relating to railroad employment; 2) Department of Veterans Affairs for
administering 38 U.S.C. 1312, and upon request, for determining eligibility for, or amount of, veterans benefits
or verifying other information with respect thereto pursuant to 38 U.S.C. 5106; 3) State welfare departments
for administering sections 205(c)(2)(B)(i)(II) and 402(a)(25) of the Social Security Act requiring information
about assigned Social Security numbers for Temporary Assistance for Needy Families (TANF) program
purposes and for determining a recipient’s eligibility under the TANF program; and 4) State agencies for
administering the Medicaid program.
To contractors and other Federal agencies, as necessary, for the purpose of assisting the Social Security
Administration (SSA) in the efficient administration of its programs. We will disclose information under the
routine use only in situations in which SSA may enter into a contractual or similar agreement with a third
party to assist in accomplishing an agency function relating to this system of records.
In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For
example, where authorized, we may use and disclose this information in computer matching programs, in
which our records are compared with other records to establish or verify a person’s eligibility for Federal
benefit programs and for repayment of incorrect or delinquent debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notice (SORN) 600090, entitled Master Beneficiary Record, as published in the Federal Register (FR) on January 11, 2006,
at 71 FR 1826. Additional information, and a full listing of all of our SORNs, is available on our website at
SSA.gov/privacy.
CMS will maintain records received during eligibility determinations from SSA in a CMS System of Records,
the Medicare Beneficiary Database (MBD) SORN 09-70-0536 as published in the Federal Register (FR) on
February 14, 2018, at 71 FR 11420. Additional information on CMS SORNs and permissible Routine Uses for
disclosure can be located at our Privacy website HHS.gov/foia/privacy/sorns/index.html.

Paperwork Reduction Act: 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 collection is 0938-0080.
The time required to complete this information collection is estimated to average 10 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, Maryland 21244-1850. Please do not send applications,
claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note
that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed
on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents,
please contact the Social Security Administration at 1-800-772-1213. TTY users can call 1-800-325-0778.
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