I-3-0-92.Exhibit - TERI Flag (Form SSA-2200)

Last Update: 9/08/05 (Transmittal I-3-36)

T E R I

CASE

NAME ___________________________________

CLAIM NUMBER _________________________

TITLE II _____ TITLE XVI ______ CONCURRENT _____

DATE IDENTIFIED AS TERI CASE ____________

____________________________________________________

DATE SENT TO: HEARING OFFICE ______ AC _______

____________________________________________________

ATTORNEY FEE

WAIVED ________

ATTORNEY FEE DIRECT

PAYMENT WAIVED ______

____________________________________________________

DO NOT REMOVE THIS FLAG UNTIL ALL

ADJUDICATIVE ACTIONS HAVE BEEN COMPLETED

AND THE APPEALS PROCESS HAS BEEN

EXHAUSTED.

Form SSA-2200 (12-2000)

LIST OF DESCRIPTORS

(Check the reason this case was identified as TERI.)

LIST OF DESCRIPTORS

A claim may be identified as a potential TERI case by using the following criteria:

1. SITUATION

______ An allegation (e.g., from the claimant, a friend, family member, doctor or other medical source) that the illness is terminal;

______ An allegation or diagnosis of AIDS;

______ The claimant is registered in a Medicare-designated hospice or is receiving hospice care; e.g., in-home counseling or nursing care; or

2. CONDITION

The claimant has a condition which medical records indicate is untreatable; that is, the condition cannot be reversed and is expected to end in death, including, but not limited to, the following list of descriptors:

______

Chronic dependence on a cardiopulmonary life-sustaining device.

______

Chronic pulmonary or heart failure requiring continuous home oxygen and is unable to care for personal needs.

______

Diabetic with one or more of the following: multiple amputations due to diabetic gangrene, recurrent cardiovascular events (infarction, failure), recurrent cerebrovascular events with neurological deficit.

______

Comatose for 30 days or more.

______

Awaiting a heart, heart/lung, liver, or bone marrow transplant (excludes kidney and corneal transplants).

______

A malignant disease (e.g., cancer), is home confined or institutionalized, with inability to care for personal needs and is unresponsive to therapy.

______

Chronic liver disease; e.g., cirrhosis, hepatitis, with history of massive gastrointestinal hemorrhage.

______

Newborn with a lethal genetic or congenital defect.

______

Other: _____________________________________________________

        (Identify)