A client who receives SSA or Railroad Retirement benefits and is eligible for SMIB Buy-in is centrally enrolled for SMIB.
For (Name of Person)
By (Name and Title of LOA)
(SSA/PCU) Sends HCFA 4040, with SSA 1610, to SSA.
(SSA) Returns SSA 1610 to SSA/PCU.
(SSA/PCU) Codes Form 552 to reflect SMIB enrollment, including Medicare claim number.
(SSA) Mails the client a Medicare Health Insurance Card reflecting SMIB entitlement.
If the person does not wish to continue the SMIB coverage, they should notify the local SSA office.
Illinois Department of Human ServicesJB Pritzker, Governor · Grace B. Hou, Secretary
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