If a premium payment is received from a beneficiary, send the check, a copy of the
CMS-264-U3, and if available a copy of the SSA-1395-BK (Receipt and Transmittal Form)
CMS, OIS, BSOG
Division of Exceptions Processing
Baltimore, Maryland 21244-1850
CMS will 1) make an adjustment in the third party system; 2) credit the beneficiary’s
account with additional money; 3) keep a ledger to show the beneficiary paid by check;
and 4) deposit the check into the HI trust fund.
If the beneficiary pays cash, deposit the cash into the HI trust fund, document this
on the CMS-264-U3, and send the CMS-264-U3 to the address above.