Employer Instructions:

If you have been asked to provide social security numbers for the CMS Data Requirements:

1. Click Here to download a sample 'Member SSN Request Letter'.  (pdf format)
   
   
2. Please customize the form with your group and contact information and distribute the form to gather depen-dent Social Security Number information from your plan participants per our letter dated Friday, February 6th, 2009.
   
3. In order to meet federal compliance regulations, please return your completed forms to Harrington Health.

Send completed forms to:
Harrington Health
Attn: Administration Department
P.O. Box 2697
Wichita, KS 67201-2697

You may also fax the forms to Harrington Health at: 
(316) 268-4898
Attn: Administration Department

If you have questions, or cannot open this form, please contact your group administrator at (316) 262-5311 or toll-free at (800) 235-7160.

Thank You.