CMS Pub. 100-02, ch. 5, § 40.1

The term Medicare beneficiary identifier (Mbi) is a general term describing a

beneficiary's Medicare identification number. For purposes of this manual, Medicare

beneficiary identifier references both the Health Insurance Claim Number (HICN) and

the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition

period and after for certain business areas that will continue to use the HICN as part of

their processes.

The following model election language may be used:

Election Not To Use Lifetime Reserve Days

I do not wish to have Medicare benefits paid on my behalf under the

lifetime reserve provisions of section 18l2 (b) of the Social Security Act

for services furnished me by (name of hospital) beginning (date).

WHERE THE ELECTION MAY TERMINATE BEFORE THE END OF THE STAY IN

ACCORDANCE WITH §40, THE FOLLOWING MAY BE INCLUDED:

The last day to which this election applies is (date).

I understand that I will be responsible for all of the hospital's charges not

reimbursed by Medicare because of this election, except those covered under

Medicare Part B. Where Medicare Part B payments may be made for services

furnished during the period covered by the election, I will be responsible for the

deductible and 20 percent coinsurance amounts.

(Signature) (Date)

(Medicare beneficiary identifier)