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HI 01001: Supplementary Medical Insurance

Effective Dates: 03/15/1999 - Present
TO: Railroad Retirement Board
  Health Insurance Operations
  844 Rush Street
  Chicago, Illinois 60611
FROM: SSA PSC NE MAT AW FL MM QN ODO DIO
SUBJECT: SMI Premium Arrearages Based on Equitable Relief

 

Take the following actions on this case:

 

    RRB claim number                

 

    SSA claim number                

 

    Name                                           

 

Check the appropriate box:

 

□ 1.  Waiver request - Development made by district office

 

□ 2.  Beneficiary in: □ current pay  □ suspense  □  uninsured status

 

Comments:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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HI 010: Premium Collections
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HI 01005: Premium Health Insurance
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