HI 00801.904 Temporary Notice of HI-SMI Eligibility — Sample
(If the individual is only eligible for HI or SMI, delete the inapplicable words)
District Office Address:
Patient's Health Insurance
Based on the information given to the Social Security Administration, you are (Mr./Ms. is) eligible for hospital insurance beginning (mo) (yr.) and for medical insurance beginning (mo.) (yr.) . This notice will serve as evidence of your (his) eligibility for these benefits
for 60 days from the date shown at the top of this notice unless you are notified
otherwise during the 60-day period.
To obtain medical services (or reimbursement for medical services) before you receive
a health insurance card, show this letter to your hospital or doctor but keep the
letter with you. This temporary notice of eligibility is to be used only by the person
to whom it is addressed. Misuse is unlawful and will make the offender liable to a
This letter should be destroyed as soon as you receive a health insurance card or
other notice of eligibility.
Commissioner of Social Security
When services are provided on the basis of this notice, all bills or correspondence
with an intermediary or the Social Security Administration should show the patient's
health insurance claim number.