[Code of Federal Regulations]
[Title 20, Volume 2]
[Revised as of April 1, 2004]
From the U.S. Government Printing Office via GPO Access
[CITE: 20CFR422.510]

[Page 1091-1092]
 
                      TITLE 20--EMPLOYEES' BENEFITS
 
               CHAPTER III--SOCIAL SECURITY ADMINISTRATION
 
PART 422_ORGANIZATION AND PROCEDURES--Table of Contents
 
                Subpart F_Applications and Related Forms
 
Sec. 422.510  Applications and related forms used in the health insurance 
for the aged program.

    (a) Application forms. The following forms are prescribed for use in 
applying for entitlement to benefits under the health insurance for the 
aged program:

SSA-18--Application for Hospital Insurance Entitlement. (For use by 
individuals who are not entitled to retirement benefits under title II 
of the Social Security Act or under the Railroad Retirement Act. This 
form may also be used for enrollment in the supplementary medical 
insurance benefits plan.)
SSA-40--Application for Enrollment in the Supplementary Medical 
Insurance Program. (This form is mailed directly to beneficiaries at the 
beginning of their initial enrollment period.)
SSA-40A--Application for Enrollment in Supplementary Medical Insurance. 
(For use by civil service employees who are not eligible for enrollment 
in the hospital insurance plan.)

[[Page 1092]]

SSA-40B--Application for Medical Insurance. (For general use in 
requesting medical insurance protection.)
SSA-40C--Application for Enrollment. (This form is mailed to 
beneficiaries as a followup on Form SSA-40 (Application for Enrollment 
in the Supplementary Medical Insurance Program).)
SSA-40F--Application for Medical Insurance. (For use by beneficiaries 
residing outside the United States.)


An individual who upon attainment of age 65 is entitled to a monthly 
benefit based on application OA-C1, SSA-2, OA-C7, OA-C10, SSA-10A, OA-
C13, or SSA-14 is automatically entitled to hospital insurance 
protection. (For conditions of entitlement to hospital insurance 
benefits, see 42 CFR part 405, subpart A. For medical insurance 
protection, an applicant must request supplementary medical insurance 
coverage (see Forms SSA-40, SSA-40A, SSA-40B, SSA-40C, and SSA-40F under 
Sec. 422.510(a)). (For conditions of entitlement to supplementary 
medical insurance benefits, see 42 CFR part 405, subpart B.)
    (b) Related forms. The following are the prescribed forms for use in 
requesting payment for services under the hospital insurance benefits 
program and the supplementary medical insurance benefits program and 
other related forms:

SSA-1453--Inpatient Hospital and Extended Care Admission and Billing. 
(To be completed by hospital for payment of hospital expenses for 
treatment of patient confined in hospital.)
SSA-1483--Provider Billing for Medical and Other Health Services. (To be 
completed by hospital for payment of hospital expenses for treatment of 
patient who is not confined in the hospital.)
SSA-1484--Explanation of Accommodation Furnished. (To be completed by 
the hospital to explain accommodation of a patient in other than a 
semiprivate (two- to four-bed) room.)
SSA-1486--Inpatient Admission and Billing--Christian Science Sanatorium. 
(To be completed by a Christian Science sanatorium for payment for 
treatment of patients confined in the sanatorium.)
SSA-1487--Home Health Agency Report and Billing. (For use by an 
organization providing home health services.)
SSA-1490--Request for Medicare Payment. (For use by patient or physician 
to request payment for medical expenses.)
SSA-1554--Provider Billing for Patient Services by Physicians. (For use 
by hospital for payment for services provided by hospital-based 
physicians.)
SSA-1556--Prepayment Plan for Group Medical Practices Dealing Through a 
Carrier. (For use by organizations (which have been determined to be 
group practice prepayment plans for medicare purposes) for reimbursement 
for medical services provided to beneficiaries.)
SSA-1660--Request for Information--Medicare Payment For Services to a 
Patient Now Deceased. (For use in requesting amounts payable under title 
XVIII to a deceased beneficiary.)
SSA-1739--Request for Enrollment Card Information by Foreign 
Beneficiary. (Used to notify beneficiaries approaching age 65 who reside 
in foreign countries that they are eligible to enroll for SMI. They 
return this form if they wish additional information and an application, 
SSA-40F.)
SSA-1966--Health Insurance Card. (This card is issued to a person 
entitled to benefits under the health insurance for the aged program and 
designates whether he is entitled to hospital insurance benefits or 
supplementary medical insurance benefits or both.
SSA-1980--Carrier or Intermediary Request for SSA Assistance.
SSA-2384--Third Party Premium Billing Request. (For use by a 
nonbeneficiary enrollee who must pay premiums by direct remittance and 
is having his premium notices sent to a third party to assure 
continuance of supplementary medical insurance.)

[32 FR 18030, Dec. 16, 1967, as amended at 38 FR 11451, May 8, 1973; 44 
FR 34943, June 18, 1979]