Complete blocks 3-6, 9, 17, 25A, 29, 34, 37 and 38 for all allowance
determinations. For interim allowances, show MIP diary coding in block 17.
Complete blocks 3-6, 9, 22 (disallowance codes for future use), 25A, 29, 34, 37 and
38 for all disallowance determinations.
Show one of the following remarks in item 34 according to the action taken.
“Section 6012 Case - Disabling Impairment continues - Eligible for Premium Medicare.”
“Section 6012 Case - Disabling Impairment Determination Pending - Interim Eligibility
for Premium Medicare.”
a. Application not filed in enrollment period
“Section 6012 Case - Not Eligible for Premium Medicare - Enrollment Not Timely.”
Show the following remark in item 34: “Section 6012 Case - Not Eligible for Premium Medicare - Disability Benefits not Terminated
due to SGA.”