Dynamic List Information
Dynamic List Data
Form #
CMS R-285
Form Title
Medicare Request for Retirement Benefit Information
Revision Date
2024-11-01
O.M.B. #
0938-0769
O.M.B. Expiration Date
2027-11-30
Special Instructions
Use this form to request a Medicare Part A (Hospital Insurance) premium reduction based on your employment by a state or local government. Submit your completed and signed form by mail, fax, or by visiting your local Social Security office in person. Find an office near you at SSA.gov/locator. Contact Social Security at 1-800-772-1213 (TTY 1-800-325-0778) with questions.