APP044
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DUPLICATE APPLICATION OPENING
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On *F1, you submitted an Application for Help With Medicare Prescription Drug Plan
Costs. Since this application raises no new issues and we processed an earlier application
for you, we are taking no further action on this application.
If you disagree with the decision we made on your earlier application, you need to
file an appeal. You may file an appeal by calling us toll-free at 1-800-772-1213.
Fill-Ins:
*F1-1 MMMM d, yyyy (date duplicate application submitted)
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APP045
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DUPLICATE MEDICARE ASSISTANCE APP BY 3RD PARTY
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We received an Application for Help With Medicare Prescription Drug Plan Costs filed
on your behalf by *F1. Since we already processed an earlier application for you,
we are taking no further action on this application.
If you disagree with the decision we made on your earlier application, you need to
file an appeal. You may file an appeal by calling us toll-free at 1-800-772-1213.
Fill-Ins:
*F1-1 TP:SINGLE (name of third party)
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REF079
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MEDICARE ASSISTANCE REFERRAL PARAGRAPH
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For information about Medicare prescription drug plans or other Medicare issues, visit
www.medicare.gov on the Internet or call toll-free 1-800-MEDICARE (1-800-633-4227). If you are deaf
or hard of hearing, you may call the Medicare TTY number toll-free at 1-877-486-2048.
For information about the extra help with the costs related to Medicare prescription
drug plans or general information about Social Security, visit our website at www.socialsecurity.gov on the Internet. You may also call Social Security toll-free at 1-800-772-1213. If
you are deaf or hard of hearing, you may call our TTY number toll-free at 1-800-325-0778.
We can answer most questions by phone.
If you do call, please have this letter with you. It will help us answer your questions.
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MPD189
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OPENING FOR PROTECTIVE FILING CLOSEOUT
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On *F1, we talked with *F2 about your eligibility for extra help with Medicare prescription
drug plan costs. Before we can decide if *F3 eligible, you must file an application.
Fill-Ins:
*F1-1 MMMM d, yyyy (date of interview) *F2-1 TP:SINGLE (you or inquirer’s name) *F3-1 Pronoun (you are/Client Name is)
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CAPC54
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CAPTION
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What To Do Next
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AFB030
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TO FILE MPD APPLICATION USING SSA’S WEBSITE
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You may complete an application right away on the Social Security Administration's
website at www.socialsecurity.gov on the Internet. If you would like a Social Security
representative to take the application for you, call us toll free at 1-800-772-1213
to schedule an appointment
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CAPC09
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CAPTION
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What Will Happen
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APP046
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ABILITY TO APPEAL DECISION ON APPLICATION
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If you file an application, we will review the claim and make a decision. If you do
not agree with what we decide, you will be able to appeal the decision.
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REFC01
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STANDARD REFERRAL CAPTION
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If You Have Any Questions
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REF038
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REFERRAL PARAGRAPH FOR T2 CASES (WITH CR NAME)
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For general information about Social Security we invite you to visit our website at
www.socialsecurity.gov on the Internet. For general questions and specific questions
about *F1 case, you may call us toll-free at 1-800-772-1213, or call your local Social
Security office at *F2 and ask for *F3. We can answer most questions over the phone.
If you are deaf or hard of hearing, you may call our TTY/TDD number *F4. If you do
call or visit an office, please have this letter with you. It will help us answer
your questions.
Fill-Ins:
*F1-1 Pronoun (your/Client Name Possessive) (Mapped Object) *F2-1 User Phone Number (Mapped Object) *F3-1 User Name (Mapped Object) *F4-1 Office TDD Number (Mapped Object)
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REF058
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WSU REFERRAL PARAGRAPH W/FO ADDRESS
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If you have any questions about your claim please call *F1 and ask for *F2. You can
also call or visit your local Social Security office. The telephone number of the
Social Security office that serves your area is *F3 and it is located at: *F4 If you do call or visit an office, please have this letter with you. It will help
us answer your questions. For general questions or information about Social Security
we invite you to visit our website at www.socialsecurity.gov or call us at 1-800-772-1213.
Fill-Ins:
*F1-1 User Phone Number (Mapped Object) *F2-1 User Name (Mapped Object) *F3-1 Office Phone Number (Mapped Object) *F4-1 Office Location Address (Mapped Object)
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REF061
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REFERRAL PARAGRAPH FOR TSC/WORK TRANSFER USE
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We invite you to visit our web site at www.socialsecurity.gov on the Internet to find
general information about Social Security. If you have any specific questions, you
may call us toll-free at 1-800-772-1213, or call your local office at *F1. We can
answer most questions over the phone. If you are deaf or hard of hearing, you may
call our TTY number, 1-800-325-0778. You can also write or visit any Social Security
office. The office that serves your area is located at:
*F2
If you do call or visit an office, please have this letter with you. It will help
us answer your questions. Also, if you plan to visit an office, you may call ahead
to make an appointment. This will help us serve you more quickly when you arrive at
the office.
Fill-Ins:
*F1-1 Servicing Office Phone Number (Mapped Object) *F2-1 Servicing Office Location Address (Mapped Object)
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MPD191
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OPENING FOR SUBSIDY APPLICATION COVER NOTICE
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On *F1, we talked with you about *F2 eligibility for extra help with Medicare prescription
drug plan costs. We filled out the enclosed, "Application for Help with Medicare Prescription
Drug Plan Costs," based on your statements. However, we cannot decide if *F3 eligible
until you sign the application and give us more information.
Fill-Ins:
*F1-1 MMMM d, yyyy (date of interview) *F2-1 TP:SINGLE (your or inquirer’s name (possessive)) *F3-1 Pronoun (you are/he is/she is/Client Name is) (Mapped Object)
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INFC06
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CAPTION
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What You Need To Do
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ELG025
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FILING AN APPLICATION FOR MPD
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Answer any questions circled on the application.
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Correct any information that is wrong.
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Sign and date the application in the space called "Your Signature." If your husband
or wife is living with you, please have him or her sign in the space called "Your
Spouse's Signature."
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Mail the application to us at the address shown above in the enclosed postage paid
envelope.
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CAPC40
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CAPTION
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If We Don't Hear From You
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MPD192
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WHEN WE MUST RECEIVE AN APPLICATION FOR PFD
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It is important that you sign the application and return it to us right away . Send it to us even if you do not have all the information. The sooner we get the
signed application, the sooner we can decide if you are eligible for extra help with
Medicare prescription drug plan costs. If we receive the signed application by *F1,
we will use *F2, the date you contacted us, as the filing date.
Fill-Ins:
*F1-1 MMMM d, yyyy (60 days from date of notice (workday)) *F2-1 MMMM d, yyyy (protective filing date)
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