TN 3 (05-99)
The claims identification information is the large block comprising the top third
of the form. There are five partitions within this block.
Take the following actions when completing the partitions.
Clearly print the SSN and BIC.
Circle the appropriate PC.
All foreign claims and totalization claims go to PC8.
All ESRD claims go to PC7.
All DIB claims for Number Holders (NH) under age 54 go to PC7.
All DIB claims for NHs age 54 or older go to the PC based on SSN.
All other claims go to the PC based on SSN.
Note: Regional instructions may override this procedure due to work sharing initiatives.
Mark the block corresponding to the type of claim being forwarded.
Note: DIB Transfer is marked when, under the work sharing initiative, a DIB claim for an
NH under age 54 is being forwarded to PC1 through PC6.
Mark the block corresponding to the process used to adjudicate the claim.
If “Initial Claim” or “DIB Transfer” has been marked, then mark one or more (if concurrent claims) blocks in this section.
Exception: Make no selection for Medicare-only or MQGE claims.