DI 45001.092 Transplant 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 36th month following the month in which the person receives a
kidney transplant, unless before that date the patient receives another transplant
or begins a course of dialysis. Since you received a transplant in , your Medicare will terminate on , unless you or your treatment center submits evidence that you have begun a course
of dialysis or received another kidney transplant.
If you have begun a course of dialysis or received another 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
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 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.