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