REMINDER: CRs in FO 872 take all EHH Medicare applications.
If MCS is not available to take the application for EHH Medicare and DIB, the CR must
take a paper SSA-16-BK (Application for Disability Insurance Benefits). The SSA-16-BK
serves as an application for both EHH Medicare and DIB.
The CR must add the following in the “REMARKS” section of the SSA-16:
I want to apply for Medicare based on exposure to environmental health hazards”;
“I was present at least a total of 6 months in Lincoln County, Montana, from MM/CCYY
NOTE: If the claimant cannot make such a statement, enter appropriate remark regarding
allegation of presence in Lincoln County, Montana.
Name of the medical source who will complete the EHH Checklist. (For more information
on developing medical requirement, see HI 00803.050.)
NOTE: If possible, load the claim in MCS prior to adjudication.