Basic (03-86)
DI 45001.091 Dialysis Cessation Pre-termination Notice of R-HI/R-SMI, and Request for Completion
of Form CMS-2728-U3, End Stage Renal Disease Medical Evidence Report Medicare Entitlement
and/or Patient Registration
This is in reference to your entitlement to health insurance based on kidney disease.
The law requires that Medicare health insurance based on kidney disease must end with
the last day of the 12th month following the month in which the person ended a regular
course of dialysis, unless before that date the patient receives a kidney transplant
or begins a new course of dialysis. Since you ceased a regular course of dialysis
in , your Medicare will terminate on , unless you or your treatment center submits evidence that you have begun a new
course of dialysis or received a kidney transplant.
If you have begun a new course of dialysis or received a transplant, please have your
treatment center complete the enclosed form CMS-2728-U3 and return it promptly (within
30 days) to the Social Security Administration in the envelope provided. If there
is any additional information or evidence you want us to consider, please submit it
without delay. You may submit it in writing, in person, or by telephone to a social
security representative.
You will receive formal notice about termination of your Medicare health insurance.
You will have an opportunity to file an appeal and to present further evidence at
that time, if you do not agree with the decision.
If you have any questions about this notice, wish to submit additional evidence or
have any difficulty in obtaining evidence regarding your transplant, please contact
your local social security office as soon as possible. If you visit an office, please
take this notice with you.
Enclosures:
Form CMS-2728-U3
Preaddressed envelope