TN 19 (03-93)

HI 00805.060 Voluntary Request for Enrollment


Section 1837 of the Social Security Act
Social Security Act
Regulations 42 CFR 407.10ff.

A. Policy - Who must enroll

While most persons are deemed to have enrolled for SMI, many individuals are excepted from automatic enrollment (see HI 00805.050) and must enroll. Those who refuse automatic enrollment, or terminate a period of SMI entitlement must enroll.

B. Policy - How to enroll

To be entitled (or reentitled) to SMI, individuals mentioned in HI 00805.060A above (or their representatives - see HI 00805.070) must file either:

  • a properly executed enrollment form, or

  • any signed statement that unequivocally shows an intent to enroll.

C. Policy - Date of enrollment

The form or statement requesting SMI can only be filed with SSA during a prescribed enrollment period.

NOTE: A form or statement is filed with SSA as of the date SSA receives it, no matter when the form shows it was signed. The mailing date may also be used as filing date, as explained in HI 00805.130.

The date of receipt (or mailing, if material) of an equivocal signed statement or improperly executed enrollment form may serve as the enrollment date. However, it must be followed by an unequivocal request for enrollment within 60 days of the date the individual is notified of the need to submit such a request.

D. Policy - Improperly completed enrollment form

Any form which is unclear about the individual's intent to enroll is an improperly completed enrollment form.

Any office receiving an improperly completed enrollment form will notify the potential enrollee that, to enroll, he/she must file, within 60 days of the date of the notice, a written statement clearly expressing this intention and bearing his/her signature or properly witnessed mark (or that of a responsible representative).

NOTE: This may be done on an enrollment form (enclosed with the notice) or on a supplemental statement.

If the individual fails to respond within 60 days, the incorrectly completed form is not effective.

Among the improperly completed enrollment forms which may establish the application date are those which the individual:

  • Signed but failed to answer “yes” or “no.”

  • Answered “yes” but failed to sign.

  • Answered both “yes” and “no” and signed or did not sign.

  • Signed with an unwitnessed mark, with or without answering “yes” or “no.”

If a person writes on an enrollment form “I am already enrolled” or a similar phrase, this means “yes.”

If the person writes “I am a welfare recipient” or any statement constituting an allegation of State buy-in coverage, the office receiving the qualified or restricted enrollment application will initiate action to resolve the issue. (See HI 00815.088.)

Enrollment forms returned by mail which have been checked “no,” but are unsigned, are treated and acknowledged as declinations. No further development will be required merely to obtain a signature.

To Link to this section - Use this URL:
HI 00805.060 - Voluntary Request for Enrollment - 03/12/1999
Batch run: 05/31/2013