This is an exhibit of the PC Reply - 2568 and 256C.
ADM PC REPLY 2568
TRANSFER TO:
ROUTING INDICATOR (TO): DATE (MMDDYY): NH NAME:
SSN: BIC: BENEFICIARY NAME:
CROSS REFERENCE SSN/BIC:
FROM
-
PC: PC CONTACT PERSON:
PHONE: FAX:
TYPE OF REPLY: 1= FINAL 2= INTERIM
TO
-
DISTRICT OFFICE (CITY/STATE):
DO CONTACT PERSON: UNIT:
TYPE OF REQUEST RECEIVED:
-
1 = CRITICAL 2489 2 = PRIORITY 2560 3 = NONPRIORITY 2560
DATED (MMDDYY):
REQUESTING
1 = CRITICAL PAY 2 = EXPEDITED PAYMENT 3 = ACTION 4 = INFORMATION 5 = FOLLOWUP
BENEFICIARY CONTACTED DIRECTLY (Y/N):
2568 PAGE 2
EXPLANATION
-
1 = PAYMENT ACTION TAKEN
2 = REQUEST IS BEING EXPEDITED - WILL ADVISE AS SOON AS POSSIBLE
3 = NO RECORD OF THIS SSN - PLEASE VERIFY AND RESUBMIT REQUEST
4 = CLAIM NOT IN THIS OFFICE - RETRANSMIT REQUEST TO PROPER PC
5 = EXCLUDED FROM THE CRITICAL PROCESS PER POMS RS 02801.000 ff.
6 = NO PAYMENT ACTION DUE - SEE EXPLANATION BELOW
7 = ACTION CANNOT BE TAKEN WITHOUT THE FOLDER - SEE EXPLANATION BELOW
8= OTHER
IF 1 IS SELECTED ENTER PAYMENT INFORMATION:
BIC: PAID AMT: FOR: RUN (MMDD): CONT AMT:
BIC: PAID AMT: FOR: RUN (MMDD): CONT AMT:
BIC: PAID AMT: FOR: RUN (MMDD): CONT AMT:
BIC: PAID AMT: FOR: RUN (MMDD): CONT AMT:
CASE INFORMATION: