TN 30 (03-96)

NL 00703.626 Notice When Claimant Protests Amount of Premium Bill (Withdrawal Model Letter)

Document Identifier for Word Processor: E3626


This notice refers to your recent letter regarding the amount of your medical insurance bill.

The Social Security Act requires that medical insurance premiums be paid l month in advance. The initial billing covers premiums for months beginning with the first month of coverage up to and including the third month of billing; subsequent billings are for periods of 3 months.

Our records indicate you received a bill for $ (1) covering payment (2) through (3) . Since your first month of coverage was (4) , the bill is correct.

You should submit your premium payment immediately if you have not already done so to avoid loss of coverage.


If You Have Any Questions






  • This notice will be used when a beneficiary inquires about the amount of premium due on his/her medical insurance bill.


  • Fill-ins:

    1. (1) 

      SMI Premium Amount Due

    2. (2) 

      Month and Year

    3. (3) 

      Month and Year

    4. (4) 


Refer to NL 00703.005E. for 3901C text.


Information for the notice will be shown on Form SSA-573. The name and address, if not given, can be taken from the latest Form SSA-3926-EP in file. The authorizer will furnish the fill-in information.

The typist should include a self-addressed envelope with the notice and the claim number should be typed on the inside of the envelope below the flap.

NOTE: The return envelope should be placed lengthwise on the left-hand side of the beneficiary notice and stapled in the upper left-hand corner.

To Link to this section - Use this URL:
NL 00703.626 - Notice When Claimant Protests Amount of Premium Bill (Withdrawal Model Letter) - 05/01/1999
Batch run: 05/01/1999