REMINDER: CRs in FO 872 take all EHH Medicare applications.
If MCS is not available to take the application for EHH Medicare and DIB, the CR must
take a paper SSA-16-BK (Application for Disability Insurance Benefits). The SSA-16-BK
serves as an application for both EHH Medicare and DIB.
The CR must add the following in the “REMARKS” section of the SSA-16:
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I want to apply for Medicare based on exposure to environmental health hazards”;
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“I was present at least a total of 6 months in Lincoln County, Montana, from MM/CCYY
to MM/CCYY”;
NOTE: If the claimant cannot make such a statement, enter appropriate remark regarding
allegation of presence in Lincoln County, Montana.
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Name of the medical source who will complete the EHH Checklist. (For more information
on developing medical requirement, see HI 00803.050.)
NOTE: If possible, load the claim in MCS prior to adjudication.