TN 4 (02-02)

GN 01020.355 Form Completion


The items on the form identify actions that must be taken by the PSCs.  In order to alert the PSCs to the needed action, the FO must check all applicable items.  The appropriate block identifying the pending action must be checked to facilitate proper routing of the material in the PSCs through PCACS.


Take the following actions when completing the partitions.

1. SSN & BIC

Clearly print the SSN and BIC information.

2. TO: PSC

Circle the appropriate PSC according to the SSN ranges provided.

  1. a. 

    All material for disabled NHs under age 54 are under the jurisdiction of ODO.

  2. b. 

    All material for disabled NHs age 54 and older are the jurisdiction of the appropriate PSC according to the SSN ranges provided.

3. Fax Routing Outing Information

Check this block when the SSA-409 is being used to forward actionable material to the PSCs by FAX.  Annotate the appropriate PSCs FAX number along with the total number of pages being forwarded, including the SSA-409 cover page.

After faxing the material to the PSC, DO NOT forward the material to the PSC by mail, as this will create a duplicate record in the PSC.

4. Response to PSC Request for Assistance

Check this block when forwarding material in response to a PSC request for assistance.  If the specific technician or location is known, annotate that information in the Attn: block.  This will speed the association of the material with the action pending in the PSC.

To Link to this section - Use this URL:
GN 01020.355 - Form Completion - 05/21/2009
Batch run: 03/29/2017