Primary Member’s Indicative Info 3) <blank> 1) Medicare Info Datasheet 2) Person record is Authorized dependent child use – 71 1045 1094 Representative 50 A/N Y Primary Member’s City Indicative Info 3) <blank> 1) Medicare Info Datasheet 2) Person record is Authorized dependent use – 72 1095 1096 Representative 2 A/N Y Primary Member’s State Indicative Info 3) <blank> 1) Medicare Info Datasheet 2) Person record is dependent child use – Primary Member’s A/N Authorized Indicative Info 73 1097 1106 Representative 10 Y 3) *See Zip Description *Zip code will be justified and padded with leading spaces. 1) Medicare Info Datasheet 2) Person record is Authorized dependent child use – 74 1107 1116 Representative 10 A/N N Primary Member’s Phone Indicative Info 3) <blank> NOT USED Employer or 75 1117 1124 8 A/N Y OSEEGIB Union Name Employer or 76 1125 1128 Union Group 4 A/N Y 9010 Number Yes=info is completed on form. Used when changing Y=Yes 77 1129 1129 Plan Change? 1 A/N Y from one plan to another N=Blank same carrier. NOT USED Info Provided Default is Y because info is Under Y=Yes “Please 78 1130 1130 1 A/N Y on the form and member Read and Sign N=No signed the form Below”? Release of Default is Y because info is Information Y=Yes 79 1131 1131 1 A/N Y on the form and member Elements N=No signed the form Provided?
Primary Member’s Indicative Info 3) <blank> 71 1045 1094 Authorized Representative City 50 A/N Y 1) Medicare Info Datasheet 2) Person record is dependent child – use Primary Member’s Indicative Info 3) <blank> 72 1095 1096 Authorized Representative State 2 A/N Y 1) Medicare Info Datasheet 2) Person record is dependent – use Primary Member’s Indicative Info 3) <blank> 73 1097 1106 Authorized Representative Zip 10 A/N *See Description Y 1) Medicare Info Datasheet 2) Person record is dependent child – use Primary Member’s Indicative Info 3) *Zip code will be justified and padded with leading spaces. 74 1107 1116 Authorized Representative Phone 10 A/N N 1) Medicare Info Datasheet 2) Person record is dependent child – use Primary Member’s Indicative Info 3) <blank> NOT USED 75 1117 1124 Employer or Union Name 8 A/N Y OSEEGIB 76 1125 1128 Employer or Union Group Number 4 A/N Y 9010 77 1129 1129 Plan Change? 1 A/N Y Y=Yes N=Blank Yes=info is completed on form. Used when changing from one plan to another same carrier. NOT USED 78 1130 1130 Info Provided Under “Please Read and Sign Below”? 1 A/N Y Y=Yes N=No Default is Y because info is on the form and member signed the form 79 1131 1131 Release of Information Elements Provided? 1 A/N Y Y=Yes N=No Default is Y because info is on the form and member signed the form
Solicitation0900000303Attachment4.docx