Complete the following forms:
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1.
SSA-450 Earnings Record Request
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3.
SSA-3687-U2 (Determination of Benefit Rights Coding Sheet)
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a.
Review and correct all items as required.
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b.
If the ESRD patient is entitled to SSI or is a Medicaid recipient, see HI 00815.030 regarding possible coverage under a State buy-in agreement. If buy-in applies, special
coding is required (FAC code PW).
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c.
Verify the appropriate coding in the MH field. Coding in this field must be correct
as the system derives the date of entitlement (DOE) from this entry.
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d.
Do not enter a Spanish notice request indicator in the CH field.
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e.
If applicable, it will be necessary to request the following paragraphs: (1) RM-30
with appropriate fill-in, when copy of notice is to be sent to a third party, (2)
Paragraph listed in DI 45001.355 A. when waiver of qualifying period based on self-care dialysis is denied.
Request the paragraphs on Form SSA-5002. Also check block 3.a. of Form SSA-3293 and
indicate in remarks: “See SSA-5002 in file for additional notice language.”
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4.
SSA-5015-U2 (when needed in successful transplant and cessation of dialysis cases).