DI 12095.170 Benefit/Payment Continuation Requests

A. Exhibit 1

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.

 I do not want any payments continued.
 I want only my payments continued.
 I want payments continued for me and everyone qualified on my Social Security Record.
 I want payments continued for everyone qualified on my Social Security Record, except myself.
 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.
 I want both Part A and Part B Medicare coverage continued.
 I want only Part A Medicare coverage continued.
  
 
SIGNATURE       
  
 
Date            
  

B. Exhibit 2

I have been advised of my right to have the social security payments I receive because of          's disability continued pending the outcome of the appeal regarding the decision that disability has ceased. I have also been advised that my payments cannot be continued unless          requests payment continuation on my behalf. If payment continuation on my behalf is requested:

 I want payments continued.
 I do not want payments continued.
 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 the Supplemental Medical Insurance coverage, and if payment is not made, the coverage will be terminated.
 I want both Part A and Part B Medicare coverage continued.
 I want only Part A Medicare coverage continued.
  
 
SIGNATURE       
  
 
Date            

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