Downloading a Form to Your Computer
Fillable forms cannot be viewed on mobile or tablet devices. Follow the steps below to download and view the form on a desktop PC or Mac.
- Right Click for PC or Ctrl + Click for Mac on the PDF link and click “Save link as” from the menu.
- Select the folder you want to save the file in and then click "Save."
- Navigate to the folder you saved the file in and Right Click for PC or Ctrl + Click for Mac, then select "Open With" from the menu and select Adobe Acrobat Reader DC.
Note: Open the PDF file from your desktop or Adobe Acrobat Reader DC. Do not click on the downloaded file at the bottom of the browser since it will not open the PDF in Adobe Acrobat Reader DC. It will try to open the file in the browser that results in the same browser error message.
To notify SAVERR Data Control, Data Support Division, state office, that Medicare insurance premiums are still being withheld from the recipient's RSDI check or Railroad Retirement check.
When to Prepare
Form H1223 is sent if Medicare premiums
- Are still being withheld after two months from certification date for the MAO program, or
- Are being withheld on ongoing MAO program transfer from Program 13 to Program 14 or Program 03.
Number of Copies
Original and two copies are legibly handwritten or typed.
Send the original and first copy to SMIB Supervisor, state office. Retain the last copy for the case record. This copy is to be destroyed when the turnaround reply is received from state office.
In reply, state office returns the first copy of Form H1223 with information on Buy-in and retains the original.
The case record copy is retained for three fiscal years in nonnursing home cases, and five fiscal years in nursing home cases. The state office copy is retained for three fiscal years.