Enter SSN in spaces 1-9. In space 10, enter “A” if the patient is receiving a reduced primary benefit or DIB (do not use HA since this will cause the input to except) or the appropriate claim symbol if the claimant is entitled to auxiliary or survivors benefits, or “T” if the patient is not receiving monthly benefits. In space 11, be sure to enter the appropriate subscript (1, 2, 3, etc.) when the claimant is a child entitled to auxiliary benefits, e.g., space 10 would show “C” and space 11 would reflect the corresponding subscript (1, 2, 3, etc.). If the patient is insured based on federal employment for appropriate BIC (space 10) and subscript (space 11) entries.
Enter first name - do not enter more letters beyond space 22. If the first name does not use the 10 spaces, leave remaining spaces blank.
Enter middle initial.
Enter surname. Do not leave any blank spaces between letters. For example, show “McCree” or “OBrien” rather than “Mc Cree” or “O"Brien.” If Jr. or Sr. is shown on the application, it needn"t be shown on the HCFA-8063, although the input will not except if Jr. or Sr. is included.
Enter date of birth.
Enter the month and year of R-HI entitlement.
Enter the month and year of R-SMI entitlement. If patient did not elect R-SMI, leave blank.
Enter sex code.
Enter “2” in space 78. A numeric entry is mandatory or the input will except.
Enter signature (see E., below).