AA-7 (XX-XX) Propo Spouse Divorced Spouse 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

DAY

OFFICE NUMBER

YEAR

SPOUSE/DIVORCED SPOUSE
APPLICATION FOR
MEDICARE
After completing through 1 Item 10, tab to the receipt on page 6 and'
complete the top half.

Section 1

APPROVED

APPLICATION NUMBER

DATE CODED
MONTH

DAY

YEAR

CODED BY

Identifying Information

Check the information entered by the Railroad Retirement Board (RRB) for Items 1 through 10 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

PREFIX

NUMBER

A

3 EMPLOYEE'S NAME
4 YOUR NAME
5 a MAILING ADDRESS
CITY AND STATE

ZIP CODE




5b FOREIGN ADDRESS

YES
NO

(IF YES) COUNTRY

6 YOUR DAYTIME TELEPHONE NUMBER
7 YOUR DATE OF BIRTH
8 YOUR SEX

Area Code

MONTH

TELEPHONE NUMBER

DAY

 MALE


FEMALE

YEAR

Go to Item 10
Go to Item 9

Form AA-7 (XX-XX) Destroy Prior Editions

9 YOUR SURNAME AT BIRTH (IF DIFFERENT FROM ITEM 4)
10 YOUR SOCIAL SECURITY NUMBER
(If none, enter "TO BE SUBMITTED")

Section 2

Information about the Employee’s Railroad Work and Military Service

11 Has anyone ever filed an application for monthly benefits or
Medicare under the Railroad Retirement Act on this
account number?





YES
NO
UNKNOWN

12 Is the employee still working in the railroad industry?




YES

13 Enter the date the employee last worked in the railroad industry.

Go to Item 14
Go to Item 13

NO

MONTH

DAY

14 Is the employee age 62 or older in the month you attain age 65?




YES

15 Does the employee have 120 or more months of railroad service?

YES

16 Does the employee have 360 or more months of railroad service?






17 Did the employee have 60 or more months of railroad service
after 1995?
18 Was the employee ever in active military service in the
U.S. Army, Navy, Air Force, U.S Space Force or Marines?

Go to Item 19
Go to Item 12
Go to Item 12

NO

YEAR

Go to Item 15
Go to Item 16

NO

Go to Item 19
Go to Item 17

YES
NO

Go to Item 19
Go to Item 17




YES
NO

Go to Item 19
Go to Item 18




YES
NO

Note: Please read the proofs 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

Applicant’s Marital History

19 Enter an "X" in the box which shows your current marital status to
the railroad employee.

 Married
 Divorced

20 Were you ever married before or since your marriage to the railroad
employee? Note: Answer “NO” if you were only remarried to the
railroad employee.




YES
NO

Go to Item 21
Go to Item 22

21 Enter the following information about each of your marriages beginning with your most recent one (do not
include marriage to the railroad employee).
Marriage Began
Date

City and State

Form AA-7 (XX-XX) Page 2

Name of Spouse

Marriage Ended
How
(Check One)





Death





Death

Divorce
Annulment

Divorce
Annulment

Date

City and State




Section 4

Death
Divorce
Annulment

Information about Social Security Entitlement

22 Have you ever filed an application for social security benefits?




YES
NO

Go to Item 23
Go to Section 5

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




YES
NO

Go to Section 5
Go to Item 24

24 Name of person on whose record you filed.
25 Social security number of person on whose record you filed.
Section 5

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).

26

Do you wish to enroll in Medicare Part B?

27

Type of Medicare Part B enrollment?




YES
NO

 IEP
 SEP
 GEP

27a. 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-7 (XX-XX) Page 3

Section 6
28

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-7 (XX-XX) Page 4

Section 7

Certification

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




YES
NO

Go to Note and Item 29
Go to Item 29

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.”
30 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)
DATE

MONTH

DAY

YEAR

31 If this certificate is signed by mark ("X") in Item 29, 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-7 (XX-XX) Page 5

Section 8

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 6 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 6, 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-7 (XX-XX) Page 6

Receipt For Your Claim

EMPLOYEE'S NAME

APPLICANT’S NAME

RAILROAD RETIREMENT BOARD CLAIM NUMBER

DATE CLAIM RECEIVED

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:

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
Form AA-7 (XX-XX) Page 7

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

Form AA-7 (XX-XX) Page 8

Day

Year

Important Notices
Paperwork Reduction Act and Privacy Act Notices
This notice is given under the Paperwork Reduction Act of 1995 and the Privacy Act of 1974. The Privacy Act requires that the Railroad
Retirement Board (RRB) tell you the following whenever we ask you for information.
1) The law which allows us to ask for the information;
2) whether that law requires you to give us that information and what, if anything, might happen to you if you do not give it to us;
3) the reason why the information is requested; and
4) the persons, organizations, and agencies to which we may release the information without your permission.
The RRB is authorized to collect the information on this form under sections 7(b) and 7(d) of the Railroad Retirement Act and sections
226, 1836 and 1840 of the Social Security Act, as amended. The information on this form is needed to enable the RRB to determine
your eligibility to monthly benefits and entitlement to hospital and/or medical insurance coverage. While you do not have to furnish the
information requested on this form, no hospital or medical insurance can be provided until an application has been received. Failure to
provide all or part of the information requested could prevent an accurate and timely decision on your claim and could result in the loss
of hospital or medical insurance.
Although the information you furnish on this form is almost never used for any other purpose than stated above, there is a possibility
that for the administration of the Railroad Retirement, Social Security, and the Centers for Medicare & Medicaid Services programs,
information may be disclosed to another person or to another government agency as follows:
1) Beneficiary identification, enrollment status and premium deductions information may be released to the Social Security
Administration and the Centers for Medicare & Medicaid Services to correlate action with the administration of Title ll and Title XVlIl
(MEDICARE) of the Social Security Act.
2) Beneficiary identification may be disclosed to third party contacts to determine if incapacity of the beneficiary or potential beneficiary
to understand or use benefits exists, and to determine the suitability of a proposed representative payee.
3) Jurisdictional clearance, premium rate, coverage election, paid-thru date, and amounts of payments in arrears may be released to
the Social Security Administration and the Centers for Medicare & Medicaid Services to assist in administering Title XVlll of the Social
Security Act.
4) The last address information may be disclosed to the Department of Health and Human Services in conjunction with the Parent
Locator Service.
5) Beneficiary identification, entitlement data and rate information may be referred to the Department of State and embassy officials to
aid in the development of applications, supporting evidence and the continued eligibility of beneficiaries and potential beneficiaries
living abroad.
6) Records may be released to the Government Accountability Office for auditing purposes and for collection of debts arising from
overpayments under Title XVlll of the Social Security Act, as amended.
7) Disclosure may be made to a congressional office from the record of an individual in response to an inquiry from the congressional
office made at the request of that individual.
8) Pursuant to a request from an employer covered by the Railroad Retirement Act or the Railroad Unemployment Insurance Act,
information regarding the RRB’s determination of Medicare entitlement, entitlement data and present address may be released to the
requesting employer for the purposes of determining entitlement to and rates of supplemental benefits payable under private employer
welfare benefit plans.
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.
Computer Matching and Privacy Protection Act Notice
The Computer Matching and Privacy Protection Act of 1988 requires the Railroad Retirement Board (RRB) to advise you that
information you have provided may be used, without your consent, in automated matching programs. These matching programs are a
computer comparison of RRB records with records kept by other Federal, state, or local governmental agencies. Information from
these matching programs can be used to establish or verify a person’s eligibility for Federally funded or administered benefit programs
and for repayment of payments or delinquent debts under these programs.

Form AA-7 (XX-XX) Page 9