Form H1233, SMIB Memorandum

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Effective Date: 1/1986


Updated: 1/1986


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

  1. Are still being withheld after two months from certification date for the MAO program, or
  2. 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.

Form Retention

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.