TN 28 (07-95)

U.S. Railroad Retirement Board
Office of Programs-Medicare Section
844 North Rush Street
Chicago IL, 60611-2092

• Claimant: _______________________

• SSN:        _______________________

• RAIL:       _______________________

Above claimant has been awarded Medicare under the End Stage Renal Disease provisions of the law. Dates of Medicare entitlement are:

• Hospital Insurance _______________

• Medical Insurance ________________

The LAF code on the MBR is “E” (RRB has jurisdiction for payment of Title II benefits). Please screen records to establish Medicare entitlement under RR number for the above dates and deduct SMI (Medical Insurance) premiums.