Medicare Request for Retirement Benefit Information (CMS-R-285)

OMB 0938-0769

This information is needed to determine whether a beneficiary meets the requirements for reduction of the Part A premium to zero.

The latest form for Medicare Request for Retirement Benefit Information (CMS-R-285) expires 2021-02-28 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form CMS-R-285 Request for Retirement Benefit Informatin Form
CMS-R-285 - Supporting Statement A_.docx Supporting Statement A
Response to Comments OMB 0938 0769.docx Supplementary Document
Crosswalk of Changes CMS R285_508.pdf Supplementary Document
Justification - Use of SSN.docx Supplementary Document
Request for Retirement Benefit Informatin Form

All Historical Document Collections

202408-0938-005	Reinstatement with change of a previously approved collection	2024-08-08
202012-0938-017	Extension without change of a currently approved collection	2020-12-29
201707-0938-005 Approved with change	Reinstatement without change of a previously approved collection	2017-07-14
201309-0938-016 Approved without change	Reinstatement without change of a previously approved collection	2013-09-13
200903-0938-005 Approved without change	Extension without change of a currently approved collection	2009-03-10
200601-0938-001 Approved without change	Extension without change of a currently approved collection	2006-01-06
200301-0938-007 Approved with change	Extension without change of a currently approved collection	2003-01-06
199911-0938-007 Approved without change	Extension without change of a currently approved collection	1999-11-19
199905-0938-007 Approved without change	New collection (Request for a new OMB Control Number)	1999-05-21