HI 00825.906 Sample MBR Reply to Combined MBR/HIM Query

Identification—111-01-1111 M JONES, 12 PCI
Address—1256 SOUTH ST, 40726
Beneficiary—M U 0601P 1273 M 0174 MARY J. SMITH
Current HIB—0773 Y 33.00 1273 S33 0773 1273
Current SMIB—0766 Y 7.20 1273 330 0766 1273
Cross-Reference—M 316-91-2454 PC 4
—W 33 632324789151

LINE 1

Identification 111-01-1111 M JONES,   P   PSC1
      1   2    3     4    5
  1. SSN (from the SSA-2467)

  2. BIC

  3. Name (from the SSA-2467)

  4. Unit Identifier (from the SSA-2467)

  5. PSC number

LINE 2

Address 1256 SOUTH ST. 40726 (No city or state shown)
      1          2 
  1. First line of address on MBR

  2. ZIP Code

LINE 3

Beneficiary M U 0601 P 1273 M 0174 Mary J. Smith
 1 2  3 4  5 6  7     8
  1. BIC

  2. LAF

  3. DOB

  4. Proof of DOB

  5. DOD

  6. LAP Code

  7. LAP Date

  8. Name of MBR

  9. Sex Code

 

LINE 4

Current HIB 0773 Y 33.00 1273 S33 0773 1273
  1 2  3   4   5   6   7
  
  1. Part A Entitlement Date

  2. Current Part A Option Code

  3. Premium Amount Collectable Part A

  4. Date of Termination Part A

  5. Third Party Code Part A

  6. Third Party Entitlement Date Part A

  7. Third Party Termination Date Part A

LINE 5

Current SMIB 0766 Y 7.20 1273 330 766 1273
  1  2   3   4   5   6   7
  
  1. Part B Entitlement Data

  2. Current Part B Option Date

  3. Premium Amount Collectable Part B

  4. Date of Termination Part B

  5. Third Party Code Part B

  6. Third Part