E3621.1 Fill-ins
*F1-1 Your
*F1-2 Beneficiary’s full name
*F2-1 You qualify
*F2-2 He qualifies
*F2-3 She qualifies
*F3-1 your
*F3-2 his
*F3-3 her
3621A Fill-ins
*F1-1 You
*F1-2 Beneficiary’s full name
*F2-1 already have
*F2-2 already has
*F3-1 you receive
*F3-2 he receives
*F3-3 she receives
*F4-1 date (select when person has only Part A)
*F4-2 dates (select when person has both Part A and Part B)
*F5-1 your
*F5-2 his
*F5-3 her
*F6-1 Part A (hospital insurance)
*F6-2 Part A (hospital insurance) and Part B (medical insurance)
3621B Fill-ins
*F1 date medical insurance begins
*F2 monthly medical insurance premiums
NOTE: Use 3621B if claimant is already entitled to D-HI only.
3621.2 Fill-ins
*F1-1 Your
*F1-2 Beneficiary’s full name
*F2-1 you receive
*F2-2 he receives
*F2-3 she receives
*F3-1 your
*F3-2 his
*F3-3 her
*F4-1 your
*F4-2 his
*F4-3 her
*F5-1 your
*F5-2 his
*F5-3 her
CTDO Fill-ins
*F1-1 Zip code
*F2-1 Zip code + 4
*F2-2 DO Code
*F3-1 Telephone area code
*F4-1 Phone exchange
*F5-1 Phone number
*F6-1 Local office address line #1
*F7-1 Local office address line #2
*F8-1 Local office address line #3
*F9-1 City and State of local office
*F10-1 Local office zip code
*F11-1 Zip + 4 of local office