TN 25 (01-04)
HI 01001.277 Sample Notice- State or Local Government Retirement System Will Pay the Premium Surcharge for Medicare Part B -- Beneficiary in Direct Bill Status
Northeastern Program Service Center
1 Jamaica Center Plaza
Jamaica, New York 11432-3898
Date: October 16, 1997
Claim Number: 000-00-0000
1212 Oak Street
Alexandria, VA ZIP
We must charge a premium surcharge on your Medicare medical insurance because you have enrolled later than you could have. Your State or local government retirement system will pay your late enrollment premium surcharge after MMYYYY. You must pay the basic Medicare medical insurance premium beginning MMYYYY.
What We Plan To Do
We will send your first bill for the basic Medicare Part B premium within three months. The monthly premiums total $XX.XX. Each bill after that will be for a 3-month period. Please contact us if you do not receive the first bill within three months.
If You Disagree With The Decision
If you disagree with the change we have made to your monthly payment, you have the right to appeal. We will review your case again and consider any new facts you have. A person who did not make the first decision will decide your case.
You have 60 days to ask for an appeal.
The 60 days start the day after you receive this letter. We assume you got this letter 5 days after the date on it unless you show us that you did not get it within the 5-day period.
You must have a good reason if you wait more than 60 days to ask for an appeal.
You have to ask for an appeal in writing. We will ask you to sign a Form SSA-561-U2, called ?Request for Reconsideration.? Contact one of our offices if you want help.
If You Have Any Questions
If you have any questions about the State or local government retirement system, please contact that office.
If you have any questions about Medicare you may call us toll-free at 1-800-772-1213, or call your local Social Security office at 1-912-264-6241. We can answer most questions over the phone. You can also write or visit any Social Security Office.
The office that serves your area is located at:
District OfficeSuite 2206295 Edsall RoadAlexandria, VA 22312
If you do call or visit an office, please have this letter with you. It will help us answer your questions. Also if you plan to visit an office, you may call ahead to make an appointment. This will help us serve you more quickly when you arrive at the office.
Assistant Regional Commissioner,
Processing Center Operations