Epstein Secrets

ocess. 1. Race, check all that apply: K White K Black, African-American c American Indian/Alaska Nativ

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

ocess. 1. Race, check all that apply: K White o Black, African-American L; American IndiarVAlaska Nati

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

rocess. 1. Race. check all that apply: L White Black. African-American Y. Native Hawaiia&Pacitic Isla

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