Superior Court of California
County of Santa Clara
Human Resources
191 North First Street
San José, CA 95113
Telephone: (408) 882-2703
Fax: (408) 882-2796
Email: RetireeBenefits@scscourt.org
HR-052 NEW 8/24/15
CERTIFICATION OF MEDICARE STATUS
This form is being completed for: Court Retiree Dependent of Retiree Survivor of Retiree
Please complete Section 1, 5 (if applicable), 6 and either Section 2, 3, or 4. Sign and date the form and return it
to: Superior Court of California, County of Santa Clara 191 North First Street, San José, CA 95113.
SECTION 1: Please complete the following information
Name of Court Retiree: (Last Name, First Name)
Name of Dependent/Survivor of Retiree
Dependent/Survivor of Retiree SSN:
SECTION 2: For Retiree or Dependent/Survivor of Retiree enrolled in Medicare Part A and B
I am enrolled in Medicare Part A and Medicare Part B. This is the information reflected on my red, white and blue
Medicare card or Notice of Entitlement from the Social Security Administration (please attach copy):
HOSPITAL (PART A) effective date:
MEDICAL (PART B) effective date
SECTION 3: For Retiree or Dependent/Survivor of Retiree claiming Medicare Ineligibility
I am not eligible for Medicare Part A (in my own right or through the work history of a current, former, or deceased
spouse). I have verified this with the Social Security Administration and have attached documentation of this fact.
SECTION 4: For Retiree or Dependent/Survivor of Retiree who works and has Employer Group Health Plan Coverage
I have deferred Medicare Part B enrollment due to working beyond age 65 and have coverage in my/my spouse’s
Employer Group Health Plan. I have attached documentation of this fact.
1. Name of current Employer:
2. Name of Group Health Plan provided by employer:
SECTION 5: For Retiree ONLY – Requirement to enroll in Medicare Statement of Understanding
I understand once I am enrolled in Medicare Part B, I must contact Human Resources and enroll in a Medicare
plan. Should I no longer be enrolled in Medicare Part B or become ineligible for Medicare Part B, I will notify
Human Resources immediately.
SECTION 6: Retiree or Dependent/Survivor of Retiree Signature
I certify that the above information is true and correct and that I have read and understood these requirements.
Signature Date
Print Name Daytime Phone #
Email Zip Code associated with Medicare Card
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