c Ineligible for Part D* c Not Enrolled in Part D (chose not to enroll)" O Kidney Disease c Disabled O Disabled but actively at work Medicare — Spouse/Dependent Name: c Enrolled in Part A: Effective Date o Ineligible for Part A* O Not Enrolled in Part A (chose not to enroll)" O Enrolled in Part B: Effect

sease 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 Part A (chose not to enroll)" u Enrolled in Part B: Effect