Attmt A_required elements_7-10-08

Attachment A

Elements required for 1-800-MEDICARE Customer Service Representatives (CSRs) to transmit disenrollment requests.

Information collected from beneficiary (also necessary to verify the caller’s identity):

Name – first & last

Medicare number (HICN)

Date of birth

Mailing address

Information determined based on beneficiary’s responses to script:

Election type

Plan contract number

Transaction code

Effective date of disenrollment

If disenrollment is requested by someone other than the beneficiary, the CSR asks that they attest to having legal authority to make a change on the beneficiary’s behalf. The CSR then adds that individual’s name and their attestation to the call record as needed.