I have been advised of my right to have disability benefits and Medicare coverage
(if applicable) continued to me and to everyone qualified on my Social Security Record
pending the outcome of the appeal regarding the decision that my disability has ceased.
I understand if I lose my appeal, I will be asked to pay this money back. I will not
be asked to pay back any Medicare benefits I received while I was appealing. If I
win my appeal, any money I am due will be paid.
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I do not want any payments continued.
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I want only my payments continued.
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I want payments continued for me and everyone qualified on my Social Security Record. |
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I want payments continued for everyone qualified on my Social Security Record, except
myself.
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If Medicare coverage is applicable for myself or anyone else qualified on my Social
Security Record, I want this coverage continued, but I do not want any disability
payments continued. I understand that I will be billed directly for any premium due
for the Supplemental Medical Insurance coverage, and if payment is not made, the coverage
will be terminated.
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I want both Part A and Part B Medicare coverage continued. |
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I want only Part A Medicare coverage continued. |
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SIGNATURE
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Date
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