AA-6 (XX-XX) Propo Employee Application for Medicare

FORM APPROVED
OMB N0. 3220-0082

UNITED STATES OF AMERICA
RAILROAD RETIREMENT BOARD

DO NOT WRITE IN THIS SPACE
OFFICIALLY FILED
MONTH

EMPLOYEE APPLICATION
FOR MEDICARE
After completing through 1 Item 8, tab to the receipt on page 5 and
complete the top half.

Section 1

DAY

OFFICE NUMBER

YEAR

APPROVED

DATE CODED
APPLICATION NUMBER

MONTH

DAY

YEAR

CODED BY

Identifying Information

Check the information entered by the Railroad Retirement Board (RRB) for Items 1 through 8 for accuracy.
If the information is correct, go to Section 2.
If the information is not correct, cross out the incorrect information and enter the correct information above it. If
the information is missing, fill it in.
1

RAILROAD EMPLOYEE’S SOCIAL SECURITY NUMBER

2

EMPLOYEE’S RAILROAD RETIREMENT CLAIM NUMBER

3

YOUR NAME

NUMBER

PREFIX

4

a

A

MAILING ADDRESS

CITY AND STATE

ZIP CODE

4b

 YES
 NO

FOREIGN ADDRESS
(IF YES) COUNTRY

Area Code

5

YOUR DAYTIME TELEPHONE NUMBER
MONTH

6

YOUR DATE OF BIRTH

7

YOUR SEX

8

YOUR SURNAME AT BIRTH (IF DIFFERENT FROM ITEM 3)

Section 2
9

TELEPHONE NUMBER

 MALE
 FEMALE

DAY

YEAR

Go to Section 2
Go to Item 8

Information About Your Railroad Work And Military Service

Does your most recent Form BA-6 show that you have
120 or more months of railroad service?

 YES
 NO

Go to Section 3
Go to Item 10

Form AA-6 (XX-XX) Destroy Prior Editions

10

Do you have 60 or more months of railroad service
after 1995?

 YES
 NO

Go to Section 3
Go to Item 11

11

Are you still working in the railroad industry?

 YES
 NO

Go to Item 13
Go to Item 12

MONTH
12

Enter the date you last worked in the railroad industry.

13

Have you ever been in active military service in the
U.S. Army, Navy, Air Force, U.S Space Force or
Marines?

YEAR

 YES
 NO

Note:Please read the RB-3 booklet to find out where to get proof of military service. Creditable military service may be
used to determine your eligibility for Medicare.

Section 3

Information About Social Security Entitlement

14

Have you ever filed an application for social
security benefits?

 YES
 NO

Go to Item 15
Go to Section 4

15

Did you file for social security benefits based on your
own wage record?

 YES
 NO

Go to Section 4
Go to Item 16

16

Name of person on
whose record you filed.

17

Social security number of person on
whose record you filed.

Section 4

Request for Enrollment In Medicare Medical Insurance Part B

In addition to applying for Hospital Insurance under Medicare Part A, you may elect to enroll in Medicare Part B. This plan helps pay for
physicians’ services and certain other medical expenses not covered by the hospital plan (Part A). If you enroll in this medical plan,
you will be required to make premium payments.
Initial Enrollment Period (IEP) is the 7-month period when you are first eligible for Medicare. This period begins 3 months before you
turn 65, includes the month you turn 65, and ends 3 months after you turn 65. Coverage begins the month after you signs up during
your IEP.
You are eligible for a Special Enrollment Period (SEP) if you are age 65 or older, or are under age 65, and disabled, did not elect to be
enrolled in Medicare Part B coverage when you became eligible and are covered under an employer group health plan based on your
own or your spouse's current employment.
The General Enrollment Period (GEP) is the time period every year from January 1 to March 31 when you can enroll in Medicare Part
B for the first time if you missed your Initial Enrollment Period (IEP) and do not qualify for the Part B Special Enrollment Period (SEP).
18

Do you wish to enroll in Medicare Part B?

19 Type of Medicare Part B enrollment?

 YES
 NO
 IEP
 SEP
 GEP

19a Complete this item only if you are filing in a Special Enrollment Period.
.
I want my Part B coverage to begin on the first day of:
Month: ______________

Year: _______________

Form AA-6 (XX-XX) Page 2

NOTE: If you enroll during the last 7 months of a Special Enrollment Period,
your Part B coverage will be effective the first day of the month after the month
in which you enroll.

Section 5
20

Remarks

This section is to be used for the continuation of answers to other items. Be sure to include the item number at the
beginning of the answer you wish to continue. You may also use this space to enter any additional information that you feel
may be important to include.

Form AA-6 (XX-XX) Destroy Prior Editions

Section 6
21

Certification
 YES
 NO

Will you have a guardian or other representative
sign this application on your behalf?

Go to Note and Item 22
Go to Item 22

Note: If answered “YES,” the guardian or other representative of the applicant must sign this application.
That person must also complete and return Form AA-5, “Application for Substitution of Payee.”
22

I know that if I make a false or fraudulent statement in order to qualify for Medicare from the Railroad Retirement Board
(RRB), I am committing a crime which is punishable under Federal law.
I certify that the information I gave to the RRB on this application is true to the best of my knowledge.
I agree to notify the RRB immediately:


If there is a change in my marital status, or



If I change my address.

YOUR SIGNATURE
(First Name, Middle
Initial, Last Name)

MONTH

DAY

YEAR

DATE

23

If this certification is signed by mark (“X”) in Item 21, two witnesses who know the person signing must sign below, giving
their full addresses and daytime telephone numbers.

a Signature of Witness

Address (Number and Street)

City, State, ZIP Code

Daytime Telephone Number

Area Code

Telephone Number

Area Code

Telephone Number

b Signature of Witness

Address (Number and Street)

City, State, ZIP Code

Daytime Telephone Number
Form AA-6 (XX-XX) Page 3

Section 7

How To Return Your Application

Before you return your application, check to make sure that:
EVERY QUESTION THAT APPLIES TO YOU HAS BEEN ANSWERED.
YOU HAVE ENTERED “UNKNOWN” IN ANY ANSWER SPACE FOR WHICH YOU WERE
UNABLE TO ANSWER A QUESTION.
YOU HAVE SIGNED AND DATED THE APPLICATION.
YOU HAVE INCLUDED ALL THE NEEDED PROOFS LISTED IN THE LETTER YOU
RECEIVED WITH THIS APPLICATION.

When you received your application, you should also have received a pre-addressed envelope. If you do not have
this envelope, you can use any envelope as long as it is addressed to the RRB office shown on page 5 of this
application. No matter which envelope you use, you must put the correct postage on the envelope. Be
careful to provide enough postage, because your application and the accompanying forms may weigh more than
a standard letter. The U.S. Postal Service will not deliver your application unless it has the correct postage.

Make one final check before you seal the envelope to ensure that the following are enclosed:
NEEDED PROOFS
THE APPLICATION FORM ITSELF
ADDITIONAL FORMS YOU WERE ASKED TO COMPLETE

Note: Make no entries on page 5, which is the receipt for your claim. After the RRB receives your
application, they will complete the blanks on the receipt and send it back to you. When you receive it,
you will know that the RRB has received your application and has started the work needed to determine
if you are entitled to Medicare. If you do not receive the receipt within two weeks after you filed this
application, please contact us so we can find out what is causing the delay.

Form AA-6 (XX-XX) Page 4

Receipt For Your Claim
APPLICANT’S NAME

RAILROAD RETIREMENT BOARD CLAIM NUMBER

DATE CLAIM RECEIVED

A
Your application for Medicare has been received and will be processed as quickly as possible. If you change
your address, or if your marital status changes, you or your representative should report the change. Always
give us your claim number when writing or calling about your claim. If you have any questions about your
claim, we will be glad to help you. If you need to personally visit one of our field offices, please call for an
appointment. You will not be refused service if you do not have an appointment, but our staff can serve you
better when an appointment is made. RRB office hours can be found on our website at www.rrb.gov.

Always Report These Changes to the RRB

► Change of Address – To avoid delay in receipt of RRB correspondence, you should also file a regular
change of address notice with your post office.

► Change of Marital Status – If you remarry or become divorced or your marriage ends due to the death
of your spouse.
How to Report Changes
You can make your reports either by telephone, mail, or in person, whichever you prefer. When a change
occurs after you are enrolled for Medicare, you or your representative should report the change at once.
To report any of the above changes, contact:

►

Telephone Number:

Form AA-6 (XX-XX) Page 5

If for some reason you cannot contact that office, you should contact:

►

U S RAILROAD RETIREMENT BOARD
844 N RUSH ST
CHICAGO IL 60611-1275
(877) 772-5772

ATTESTATION
I understand that anyone who, knowingly and willfully — (1) falsifies, conceals, or covers up by any trick,
scheme, or device a material fact; or (2) makes any materially false, fictitious, or fraudulent statements or
representations, or makes or uses any materially false writing or document knowing the same to contain any
materially false, fictitious, or fraudulent statement or entry, in connection with the delivery of or payment for
health care benefits, items, or services, shall be fined or imprisoned not more than 5 years, or both.
Signature (Do not print)
Date Signed
Month

Day

Year

PAPERWORK REDUCTION ACT AND PRIVACY ACT NOTICES
The Railroad Retirement Board (RRB) is authorized to collect the information requested on this form under Sections
7(b)6 and 7(d) of the Railroad Retirement Act. The information obtained from this form will be used for determining
whether the claimant applying for Part B under Medicare may be entitled to a Special Enrollment Period and/or
premium surcharge relief because of coverage under an employer Group Health Plan. Although you are not required
to furnish this information, if you fail to do so, the claimant may not be considered eligible by the RRB to receive these
benefits.
We estimate this form takes an average of 8 minutes per response to complete, including the time for reviewing the
instructions, obtaining the data, and reviewing the completed form. If you wish, send comments regarding the
accuracy of our estimate, or any other aspect of this form, including suggestions for reducing completion time, to:
Railroad Retirement Board, ATTN: Bureau of Information Services/Policy & Compliance, 844 N. Rush St., Chicago, IL
60611-1275.

Form AA-6 (XX-XX) Page 6