The CMS-2178-U2 (see Exhibit HI 00930.090) is a two page form which the FO uses to
notify the PC and/or CMS, of needed corrections to both the MBR and the health insurance
record. It is also used to effect all changes on the Health Insurance card (HCFA-1966).
These include misspelled given names or surnames and incorrect sex, if direct input
cannot be used (see HI 00901.245). The CMS-2178-U2 should be used for entitlement issues which cannot be corrected
by FO direct input, and not for routine premium issues.
Before using the form CMS-2178-U2 process, consideration must be given to use of the
following direct input facilities:
Form SSA-3709 (MBR corrections)—To correct name/sex/day of death data in the MBR.
This action will subsequently update the HIM. (See SM 00706.075-SM 00706.080.)
Form HCFA-3274 (HI corrections)—To change or remove date of death data in the HI system
only. (See SM 00706.090.)
Form SSA-2467 (Request for HI/MBR/SSR Information or HI card)—To request replacement
HI card issuance. (See SM 00706.035.)
Also, if a state buy-in problem exists do not use Form CMS-2178-U2. Instead, use Form
CMS-1957, (See HI 00815.088.)