Ask for each person with "Covered" or "DK" in 1b
2. May I please see the Social Security Medicare card(s) for -- (and --) to determine the type of coverage and to record the Health Insurance Claim Number. Providing the Health Insurance Claim Number is voluntary and collected under the authority of the Public Health Service Act. There will be no effect on -- benefits and no information will be given to any other government or non-government agency.
Read if necessary The Public Health Service Act is Title 42, United States Code, Section 242k.
Transcribe the number, then mark the appropriate box(es).

Ask for each person with "Card NA" in 2
3a. Is -- now covered by the part of Social Security Medicare which pays for hospital bills?

b. Is -- now covered by that part of Medicare which pays for doctor's bills? This is the Medicare plan for which [he/she] or some agency must pay a certain amount each month.

Ask for each person with "Covered" in 1b.
2a. Is -- covered by the part of Social Security Medicare which pays for hospital bills? Mark box in person's column.

b. Is -- now covered by that part of Medicare which pays for doctor's bills? This is the Medicare plan for which -- or some agency must pay a certain amount each month?
Mark box in person's column.

Ask for each person with "Covered" in 1b.
2a. Is -- covered by the part of Social Security Medicare which pays for hospital bills? Mark box in person's column.

b. Is -- now covered by that part of Medicare which pays for doctor's bills? This is the Medicare plan for which -- or some agency must pay a certain amount each month?
Mark box in person's column.

Ask for each person with "Covered" in 1b.
2a. Is -- covered by the part of Social Security Medicare which pays for hospital bills? Mark box in person's column.

b. Is -- now covered by that part of Medicare which pays for doctor's bills? This is the Medicare plan for which -- or some agency must pay a certain amount each month? Mark box in person's column.

Ask for each person with "Covered" in 1b.
2a. Is -- covered by that part of Social Security Medicare which pays for hospital bills? Mark box in person's colum.

b. Is -- covered by that part of Medicare which pays for doctor's bills, that is, the Medicare plan for which he or some agency must pay a certain amount each month? Mark box in person's column.