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' � 1 , <br /> ATTACHMENT I <br /> Page 1 of 2 <br /> DATA FOR FUTURE DATA MATCH INITIATI�'E <br /> I <br /> Listed below are the data that each Settling Plan will send to HCFA in satisfaction of its ' <br /> obligations under the Future Data Match Initiative set out in Paragraph C of the <br /> Agreement, incorporated into the Agreement by reference in Paragraph C (3)(b). <br /> INFORMATION ON THE MEDICARE BENEFICIARY <br /> • Benefici Name <br /> �Y <br /> . <br />, Date of Birth <br /> • Sex <br /> • Social Securitv Number <br /> • Health Insurance Claim Number <br /> • Relationship to Policyholder � <br /> - Policyholder <br /> - Spouse of Policyholder <br /> - Child of Policyholder <br /> - Other relationship to Policyholder � <br /> • Reason for Medicare Entitlement <br /> i <br /> - Beneficiary entitled due to age ' <br /> - Beneficiary entitled due to disability <br /> - Beneficiary entitled due to End Stage Renal Disease (ESRD) <br /> - Beneficiary entitled due to disability and current ESRD <br /> INFORMATION ON POLICYHOLDER <br /> • Policyholder Name <br /> � Social Security Number <br /> • Individual Policy Number of Policyholder <br />