TN 1 (07-04)

Whenever these paragraphs are needed, they must be requested on Form SSA-5002. They must be written out with the fill-ins inserted.

A. Waiver of qualifying period based on self-dialysis training is denied

The qualifying period for Medicare entitlement based on dialysis has not been waived. Although you participated in self-care dialysis training, 1, 2, or 3 below :

Enter whichever of the following applies:

1. you did not receive this training in an approved facility.

2. you did not begin the training program before the end of the qualifying period.

3. you were not expected to complete the training and self-dialyze thereafter.

B. Qualifying period waived due to previous R-HI

Because you were previously entitled to Medicare based on renal disease, the qualifying period after dialysis has been waived.

C. Premium arrearage of 6 months or more involved - claimant elects SMI as of month of filing or as of current operating month

Your supplementary medical insurance (SMI) entitlement begins later than your hospital insurance because of 1. or 2. below:

Enter whichever applies:

1. You requested we begin your SMI the month you filed your application for Medicare based on chronic renal disease.

2. You requested we begin your SMI the month your enrollment was processed.