HI 00801: Hospital Insurance Entitlement
TN 28 (07-95)
U.S. Railroad Retirement Board
Office of Programs-Medicare Section
844 North Rush Street
Chicago IL, 60611-2092
Claimant: _______________________
SSN: _______________________
RAIL: _______________________
Above claimant has been awarded Medicare under the End Stage Renal Disease provisions of the law. Dates of Medicare entitlement are:
Hospital Insurance _______________
Medical Insurance ________________
The LAF code on the MBR is “E” (RRB has jurisdiction for payment of Title II benefits). Please screen records to establish Medicare entitlement under RR number for the above dates and deduct SMI (Medical Insurance) premiums.