Request for Medicare Payment

OMB 3220-0131

The Railroad Retirement Board (RRB) administers the Medicare program for persons covered by the Railroad Retirement System. The collection obtains the information needed by Palmetto GBA, the RRB's carrier, to pay claims for services covered under Part B of the program.

The latest form for Request for Medicare Payment expires 2022-09-30 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form G-740S (06-18) Request for Medicare Payment Form and Instruction
3220-0131 .docx Supporting Statement A
Section 7(d) of Railroad Retirement Act Of 1974.pdf Supporting Statement B
Request for Medicare Payment Form and Instruction

All Historical Document Collections

202209-3220-003 Approved without change	Extension without change of a currently approved collection	2022-09-21
201902-3220-005 Approved with change	Revision of a currently approved collection	2019-04-30
201603-3220-007 Approved without change	Extension without change of a currently approved collection	2016-03-28
201211-3220-002 Approved without change	Revision of a currently approved collection	2012-11-20
200908-3220-001 Approved without change	Revision of a currently approved collection	2009-09-25
200607-3220-001 Approved without change	Extension without change of a currently approved collection	2006-07-11
200308-3220-003 Approved without change	Extension without change of a currently approved collection	2003-08-21
200208-3220-001 Approved without change	Extension without change of a currently approved collection	2002-08-15
199906-3220-002 Approved without change	Extension without change of a currently approved collection	1999-06-30
199606-3220-003 Approved without change	Extension without change of a currently approved collection	1996-06-25
199306-3220-001 Approved without change	Extension without change of a currently approved collection	1993-06-02
199201-3220-001 Approved without change	Extension without change of a currently approved collection	1992-01-31
199104-3220-002 Approved without change	Revision of a currently approved collection	1991-04-03
198904-3220-004 Approved with change	No material or nonsubstantive change to a currently approved collection	1989-04-03
198811-3220-004 Approved without change	Revision of a currently approved collection	1988-11-22
198802-3220-004 Approved with change	No material or nonsubstantive change to a currently approved collection	1988-02-11
198710-3220-003 Approved with change	No material or nonsubstantive change to a currently approved collection	1987-10-02
198609-3220-001 Approved with change	No material or nonsubstantive change to a currently approved collection	1986-09-30
198510-3220-002 Approved without change	Revision of a currently approved collection	1985-10-01
198509-3220-009 Approved with change	No material or nonsubstantive change to a currently approved collection	1985-09-09
198408-3220-003 Approved with change	No material or nonsubstantive change to a currently approved collection	1984-08-22
198209-3220-002 Approved without change	Revision of a currently approved collection	1982-09-03
198107-3220-003 Approved without change	New collection (Request for a new OMB Control Number)	1981-07-16