Epstein Secrets

o enroll)" c Enrolled in Part B: Effective Date c Enrolled in Part D: Effective Date Reason for Medicare eligibility: O Over 65 Are you receiving Social Security Disability Insurance (SSDI)? ci YES O NO Start Date O Ineligible for Part B* O Not Enrolled in Part B (chose not to enroll)** c Ineligible for Part D* c Not Enrolled

nitedHealthcare representative in writing, except to the extent that action has already been taken in reliance on this authorization. As required by HIPAA, UnitedHealthcare also requires that I acknowledge the following, which I do: I understand that information I authorize a person or entity to obtain

chose not to enroll)' • Reason for Medicare eligibility: o Over 65 o Kidney Disease o Disabled o Disabled but actively at work Are you receiving Social Security Disability Insurance (SSDI)? o YES o NO Start Date Medicare — Spouse/Dependent Name: o Enrolled in Part A: Effective Date c Ineligible for Pail A' o Not Enrolled in

nitedHealthcare representative in writing, except to the extent that action has already been taken in reliance on this authorization. As required by HIPAA. UnitedHealthcare also requires that I acknowledge the following, which I do: I understand that information I authorize a person or entity to obtain

in Part D: Effective Date Reason for Medicare eligibility: Over 65 • Kidney Disease Disabled (2 Disabled but actively at work Are you receiving Social Security Disability Insurance (SSDI)? , . YES c: NO Start Date ___ If enrolled in Medicare, please attach a copy of your Medicare ID card. Ineligible for Part A' Not Enrolled

UnitedHealthcare representative in wnting, except to the extent that action has already been taken in reliance on this authorization. As required by HIPAA. UnitedHealthcare also requires that I acknowledge the following, which I do. I understand that information I authorize a person or entity to obtain