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

3901C

 

Enclosure:

Envelope

• •

  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) 

     Month

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.