OMB.report

Federal forms, ICRs, and supporting documents

OMB control number

Request for Medicare Payment

OMB 3220-0131 ยท RRB.

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 2029-05-31 and is listed under ICR 202601-3220-003.

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
DocumentType
Form CMS-1500 (02-12) Health Insurance Claim FormForm and Instruction
Form G-740S (06-18) Patient's Request for Medicare PaymentForm and Instruction
3220-0131_Final.docxSupporting Statement A
Section 7(d) of Railroad Retirement Act Of 1974.pdfSupporting Statement B
Request for Medicare Payment Form and Instruction
Request for Medicare Payment Form and Instruction

All Historical Document Collections

Historical document collections
ReferenceFilingReceivedConcludedAction
202601-3220-003 Revision of a currently approved collection 2026-01-26
202209-3220-003 Extension without change of a currently approved collection 2022-09-21 Approved without change
201902-3220-005 Revision of a currently approved collection 2019-04-30 Approved with change
201603-3220-007 Extension without change of a currently approved collection 2016-03-28 Approved without change
201211-3220-002 Revision of a currently approved collection 2012-11-20 Approved without change
200908-3220-001 Revision of a currently approved collection 2009-09-25 Approved without change
200607-3220-001 Extension without change of a currently approved collection 2006-07-11 Approved without change
200308-3220-003 Extension without change of a currently approved collection 2003-08-21 Approved without change
200208-3220-001 Extension without change of a currently approved collection 2002-08-15 Approved without change
199906-3220-002 Extension without change of a currently approved collection 1999-06-30 Approved without change
199606-3220-003 Extension without change of a currently approved collection 1996-06-25 Approved without change
199306-3220-001 Extension without change of a currently approved collection 1993-06-02 Approved without change
199201-3220-001 Extension without change of a currently approved collection 1992-01-31 Approved without change
199104-3220-002 Revision of a currently approved collection 1991-04-03 Approved without change
198904-3220-004 No material or nonsubstantive change to a currently approved collection 1989-04-03 Approved with change
198811-3220-004 Revision of a currently approved collection 1988-11-22 Approved without change
198802-3220-004 No material or nonsubstantive change to a currently approved collection 1988-02-11 Approved with change
198710-3220-003 No material or nonsubstantive change to a currently approved collection 1987-10-02 Approved with change
198609-3220-001 No material or nonsubstantive change to a currently approved collection 1986-09-30 Approved with change
198510-3220-002 Revision of a currently approved collection 1985-10-01 Approved without change
198509-3220-009 No material or nonsubstantive change to a currently approved collection 1985-09-09 Approved with change
198408-3220-003 No material or nonsubstantive change to a currently approved collection 1984-08-22 Approved with change
198209-3220-002 Revision of a currently approved collection 1982-09-03 Approved without change
198107-3220-003 New collection (Request for a new OMB Control Number) 1981-07-16 Approved without change