Facets

Member ID: 53252345-01

Name: Brown, Sue

Relationship: Wife

DOB: 01/01/1972

Group: G1234

Eff. Date: 01/01/2009

External ID: 9896695

Other Family Members: Yes

Medicare

Event	Effective	Medicare No.	State	County	PBP ID	Segment	Input	Verification

01	Pharmacy	O	C	O
02	Telehealth Provided Other than in Patient's Home	O	C	O
03	School	O	C	O
04	Homeless Shelter	I	C	O
05	Indian Health Service Free-standing Facility	O	C	O
06	Indian Health Service Provider Based Facility	O	C	O
07	Tribal 638 Free-standing Facility	O	C	O
08	Tribal 638 Free-standing Facility	O	C	O
09	Prison/Correctional Facility	O	C	O
10	Telehealth Provided In Patient's Home	I	C	O
11	Office	O	C	O
12	Home	O	C	O

Details

Event:

SCCC

Effective Date:

01/01/2021

Termination Date:

PBP ID:

new PBP ID

Segment ID:

123

Signature ID

12/12/2020

Election Type:

I Inital Enrol Period (ICEP)

Menu 2

Dyanmic Tab Mockup

Menu 3

Dyanmic Tab Mockup

Menu 4

Dyanmic Tab Mockup

Menu 5

Dyanmic Tab Mockup

Menu 6

Dyanmic Tab Mockup

Menu 7

Dyanmic Tab Mockup

Menu 8

Dyanmic Tab Mockup

Menu 9

Dyanmic Tab Mockup

Menu 10

Dyanmic Tab Mockup

Menu 11

Dyanmic Tab Mockup

Menu 12

Dyanmic Tab Mockup

Menu 13

Dyanmic Tab Mockup