HI 00825.913 Health Insurance Printout (HIPO)

The Items on the HIPO relevant to possible PSC action are as follows:

1. 1. 

   Account number and subscript

2. 2. 

   Last Name (up to six positions)

   First Name (up to 11 positions)

   Middle Initial (one position)

3. 3. 

   Sex

4. 4. 

   Cross-Reference Account Number and Subscript

5. 5. 

   Part A Current Entitlement Date

6. 6. 

   Part A Current Termination Date

7. 7. 

   Part A Current Option Code

8. 8. 

   Part A Previous Entitlement Date

9. 9. 

   Part A Previous Termination Date

10. 10. 

    Part A Previous Option Code

11. 11. 

    Date of Birth

12. 12. 

    Date of Accretion (date HI record established)

13. 13. 

    Date of Last Action (date of last HI action)

14. 14. 

    Part B Current Entitlement Date

15. 15. 

    Part B Current Termination Date

16. 16. 

    Part B Curret Option Code

17. 17. 

    Part B Previous Entitlement Date

18. 18. 

    Part B Previous Termination Date

19. 19. 

    Part B Previous Option Code

20. 20. 

    Date of Death

21. 21. 

    Ledger Account Status