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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES FORM APPROVED OMB NO. 0938-0787 REQUEST FOR EMPLOYMENT INFORMATION From Telephone No. Social Security Administration Employer s Name and Address Date Employee s Social Security Number Claimant s Name Claim Number Dear Sir/Madam We need the following information regarding the above claimant. You may call at the above telephone number if you have any questions. Sincerely Office Manager 1. Is or was the claimant covered under an Employer Group Health Plan Yes No 2. If yes give the original date the coverage began. mm/yyyy 3. Has the coverage ended 5. When did the employee work for your company From Signature and Title of Company Official To Still Employed Telephone Number According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information is 0938-0787. The time required to complete this information collection is estimated to average 15 minutes per response including the time to review instructions search existing data resources gather the data needed and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate s or suggestions for improving this form please write to CMS 7500 Security Boulevard N2-14-26 Baltimore Maryland 21244-1850. U*S* DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES FORM APPROVED OMB NO. 0938-0787 REQUEST FOR EMPLOYMENT INFORMATION From Telephone No* Social Security Administration Employer s Name and Address Date Employee s Social Security Number Claimant s Name Claim Number Dear Sir/Madam We need the following information regarding the above claimant. Please answer the questions below sign and date this letter and return it in the enclosed envelope. You may call at the above telephone number if you have any questions. Sincerely Office Manager 1. Is or was the claimant covered under an Employer Group Health Plan Yes No 2. If yes give the original date the coverage began* mm/yyyy 3. Has the coverage ended 5. When did the employee work for your company From Signature and Title of Company Official To Still Employed Telephone Number According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless it displays a valid OMB control number. 0938-0787 REQUEST FOR EMPLOYMENT INFORMATION From Telephone No* Social Security Administration Employer s Name and Address Date Employee s Social Security Number Claimant s Name Claim Number Dear Sir/Madam We need the following information regarding the above claimant. Please answer the questions below sign and date this letter and return it in the enclosed envelope. Please answer the questions below sign and date this letter and return it in the enclosed envelope. You may call at the above telephone number if you have any questions. Sincerely Office Manager 1. Is or was the claimant covered under an Employer Group Health Plan Yes No 2. .

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