BASIC (05-04)

DI 45605.002 Exhibit 1 - ALS Coversheet Flag

NAME:_____________________________

SSN:_____________________________

ALS CASE –

EXPEDITED ACTION NEEDED!

(P.L. 106-554 waives 24-month Medicare waiting period for

Amyotrophic Lateral Sclerosis)

FROM: FO           (enter FO name & code)

_____ SSA-795 (Example 1, DI 11036.003 )

_____ SSA-827s

Medicare waiting period _________to_________.

*See POMS DI 11036.000 for FO instructions

TO: DDS/FDDS (enter DDS site code)

Case referred to DDS for ALS determination.

*See POMS DI 23580.000 for DDS instructions

ROUTE from DDS/FDDS to FO:

ROUTE from DDS/FDDS to PC:
*See POMS DI 45605.000 for PC instructions

DO NOT REMOVE FLAG FROM FOLDER JACKET


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0445605002
DI 45605.002 - Exhibit 1 - ALS Coversheet Flag - 05/06/2004
Batch run: 01/27/2009
Rev:05/06/2004