AA-104 (proposed) Application for Canadian Hospital Benefits Under Medicar

Form Approved

United States of America
Railroad Retirement Board

OMB No 3220-0086

APPLICATION FOR CANADIAN HOSPITAL BENEFITS
UNDER MEDICARE - PART A
-

1. Your Provincial Hospital Insurance Number. .................
Copy From Your Health Insurance (HI) Card

3. HI Claim Number

2. Name of Beneficiary (Patient)

4. Sex

D
5. Were you an inpatient in a hospital, nursing home, or convalescent hospital
in the 60-day period before the first day you were furnished the services

D

Female

DYes - Go to Section 1

o No - Go to Section 2

covered by this claim?
Section 1

Male

Services provided before period of this claim

6a. Enter an "X" in the appropriate box and the period of service.

Day

Month

Year

D

Hospital ............................................................................ t-A_d_m_it_te_d_ _+---'-_-t-_-'-----Ir----'-_-'--_'----1
Discharged

D

Admitted
Nursing Home/Convalescent Hospital ............................ 1-------\---'---+--'---+----'---'---'------1
Discharged

b. Enter the name and address of the hospital or
nursing home in which you were an inpatient in
the 60-day period before the first day you were
furnished the services covered by this claim.

Section 2

..............

Full Address (Include City, Province, ZIP Code)

Services covered by this claim

7a. Enter an "X" in the appropriate box and the period of service covered by this
Year
Month
Day
claim.
Admitted
In-Patient Hospital ........................................................... 1------+--.1....---+----'---+--..1....---"---1..--1
Discharged

D
D

Admitted
In-Patient Nursing Home/Convalescent Hospital .......... 1-------\---1--+--'---+---'----'---'------1

D

Home Health ........ ...

Enter total number
of visits _ _ __

b. Only complete this item if the address is different
from Item 6b above.

.......... 1 - - - ­

..........

Name of Hospital or Nursing Home
Full Address (Include City, Province, ZIP Code)

Otherwise, enter an "X" in the box
to indicate the address is the same ........ iii>

0

8. Describe the illness or injury or which you received treatment.

9. Was your illness or injury connected with your employment? ...................................... ...
10a. Were you billed for any of the services furnished? ........... .................. ............. ......... ...
b.

How much did you pay? ........................................................................................... ...

AA-104

(xx-xx) DESTROY PRIOR EDITIONS

DYes
No
DYes - Go to Item 10b
No - Go to Item 11

o
o
$

11.

Please verify that you have furnished all information requested by signing and dating this form. You must also
enclose:
• your doctor's certification that the service was medically necessary (certification is not required if any part of the
charges for such services is payable under a provincial program), and
• your receipted bills.
Return this form to:

U.S. Railroad Retirement Board
844 North Rush Street
Chicago, IL 60611-2092

12.

Signature of Patient ........ til>

13.

Street Address ............... til>

I

Date til>

I

City and Province ........... til>
Area Code

Telephone Number

Daytime Telephone Number............... til>

I
14.

I

I

I

I

I

I

I

If this form is signed by mark ("X") in Item 12, two witnesses who know the person signing must sign below giving
their full addresses and daytime telephone numbers.
a.

Signature of Witness .............. til>

Address ..................................... til>

Area Code

Telephone Number

Daytime Telephone Number ..... til>

I
b.

I

I

I

I

I

I

I

I

I

Signature of Witness .............. til>

Address .................................... til>

Area Code

Telephone Number

Daytime Telephone Number ..... til>

I

I

I

I

I

I

PAPERWORK REDUCTION ACT AND PRIVACY ACT NOTICES
We are authorized to ask you for information needed in the administration of the Medicare program. Authority to collect information
is in sections 7(b) and 7(d) of the Railroad Retirement Act (RRA).
The information we obtain on your Medicare claim is used to identify you and to determine your eligibility. It is also used to decide
if the services and supplies you received are covered by Medicare and to make proper payment.
The information may also be given to other providers of services, carriers, intermediaries, medical review boards, and other
organizations as necessary to administer the Medicare program. For example, it may be necessary to disclose information
about the Medicare benefits you have used to a hospital or doctor.
With one exception, which is discussed below, there are no penalties under railroad retirement law for refusing to supply information.
However, failure to furnish the amount charged would prevent payment of the claim. Failure to furnish any other information, such
as name or claim number, would delay payment of the claim.
It is mandatory that you tell us if you are being treated for work-related injury so we can determine whether worker'S compensation
will pay for the treatment. Section 13(a) of the RRA provides criminal penalties for withholding this information.
We estimate this form takes an average of 10 minutes per response to complete, including the time for reviewing the instructions,
getting the needed data, and reviewing the completed form. Federal agencies may not conduct or sponsor, and respondents are
not required to respond to, a collection of information unless it displays a valid OMB number. 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 Chief of
Information Resources Management, Railroad Retirement Board, 844 Rush St., Chicago, Illinois 60611-2092.
AA-104 (xx-xx)