(Enter the beneficiary's name and address.)
In reply to your request regarding your Medicare entitlement, our records indicate
that you were born on (date), and you have been entitled to hospital insurance benefits
since (date), and to supplementary medical benefits since (date). Benefits payable
under this insurance are those authorized under Title XVIII of the Social Security
The monthly premium payment for the supplementary medical insurance benefits was (amount)
per month effective (date). (This was raised to (amount) per month effective (date)).
[For beneficiaries first entitled after a change in premium rate, omit this sentence.]
[If the beneficiary is enrolled in Premium-Part A,add a paragraph stating the monthly
Payments are made under both the hospital insurance and supplementary medical insurance
without regard to the financial status of the individual. These payments, except in
certain limited instances, are made only for health care expenses incurred within
the United States.