BASIC (05-05)

HI 03092.010 UTI’s for DPS

APP044

DUPLICATE APPLICATION OPENING

On *F1, you submitted an Application for Help With Medicare Prescription Drug Plan Costs. Since this application raises no new issues and we processed an earlier application for you, we are taking no further action on this application.

   

If you disagree with the decision we made on your earlier application, you need to file an appeal. You may file an appeal by calling us toll-free at 1-800-772-1213.

   

Fill-Ins:

*F1-1 MMMM d, yyyy (date duplicate application submitted)

  

APP045

DUPLICATE MEDICARE ASSISTANCE APP BY 3RD PARTY

We received an Application for Help With Medicare Prescription Drug Plan Costs filed on your behalf by *F1. Since we already processed an earlier application for you, we are taking no further action on this application.

    

If you disagree with the decision we made on your earlier application, you need to file an appeal. You may file an appeal by calling us toll-free at 1-800-772-1213.

   

Fill-Ins:

*F1-1 TP:SINGLE (name of third party)

  

REF079

MEDICARE ASSISTANCE REFERRAL PARAGRAPH

For information about Medicare prescription drug plans or other Medicare issues, visit www.medicare.gov on the Internet or call toll-free 1-800-MEDICARE (1-800-633-4227). If you are deaf or hard of hearing, you may call the Medicare TTY number toll-free at 1-877-486-2048.

    

For information about the extra help with the costs related to Medicare prescription drug plans or general information about Social Security, visit our website at www.socialsecurity.gov on the Internet. You may also call Social Security toll-free at 1-800-772-1213. If you are deaf or hard of hearing, you may call our TTY number toll-free at 1-800-325-0778. We can answer most questions by phone.

    

If you do call, please have this letter with you. It will help us answer your questions.

  

MPD189

OPENING FOR PROTECTIVE FILING CLOSEOUT

On *F1, we talked with *F2 about your eligibility for extra help with Medicare prescription drug plan costs. Before we can decide if *F3 eligible, you must file an application.

   

Fill-Ins:

*F1-1 MMMM d, yyyy (date of interview)
*F2-1 TP:SINGLE (you or inquirer’s name)
*F3-1 Pronoun (you are/Client Name is)

  

CAPC54

CAPTION

What To Do Next

  

AFB030

TO FILE MPD APPLICATION USING SSA’S WEBSITE

You may complete an application right away on the Social Security Administration's website at www.socialsecurity.gov on the Internet. If you would like a Social Security representative to take the application for you, call us toll free at 1-800-772-1213 to schedule an appointment

  

CAPC09

CAPTION

What Will Happen

  

APP046

ABILITY TO APPEAL DECISION ON APPLICATION

If you file an application, we will review the claim and make a decision. If you do not agree with what we decide, you will be able to appeal the decision.

  

REFC01

STANDARD REFERRAL CAPTION

If You Have Any Questions

  

REF038

REFERRAL PARAGRAPH FOR T2 CASES (WITH CR NAME)

For general information about Social Security we invite you to visit our website at www.socialsecurity.gov on the Internet. For general questions and specific questions about *F1 case, you may call us toll-free at 1-800-772-1213, or call your local Social Security office at *F2 and ask for *F3. We can answer most questions over the phone. If you are deaf or hard of hearing, you may call our TTY/TDD number *F4. If you do call or visit an office, please have this letter with you. It will help us answer your questions.

   

Fill-Ins:

*F1-1 Pronoun (your/Client Name Possessive) (Mapped Object)
*F2-1 User Phone Number (Mapped Object)
*F3-1 User Name (Mapped Object)
*F4-1 Office TDD Number (Mapped Object)

  

REF058

WSU REFERRAL PARAGRAPH W/FO ADDRESS

If you have any questions about your claim please call *F1 and ask for *F2. You can also call or visit your local Social Security office. The telephone number of the Social Security office that serves your area is *F3 and it is located at:

                        *F4

If you do call or visit an office, please have this letter with you. It will help us answer your questions. For general questions or information about Social Security we invite you to visit our website at www.socialsecurity.gov or call us at 1-800-772-1213.

   

Fill-Ins:

*F1-1 User Phone Number (Mapped Object)
*F2-1 User Name (Mapped Object)
*F3-1 Office Phone Number (Mapped Object)
*F4-1 Office Location Address (Mapped Object)

  

REF061

REFERRAL PARAGRAPH FOR TSC/WORK TRANSFER USE

We invite you to visit our web site at www.socialsecurity.gov on the Internet to find general information about Social Security. If you have any specific questions, you may call us toll-free at 1-800-772-1213, or call your local office at *F1. We can answer most questions over the phone. If you are deaf or hard of hearing, you may call our TTY number, 1-800-325-0778. You can also write or visit any Social Security office. The office that serves your area is located at:

    

                  *F2

    

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.

   

Fill-Ins:

*F1-1 Servicing Office Phone Number (Mapped Object)
*F2-1 Servicing Office Location Address (Mapped Object)

  

MPD191

OPENING FOR SUBSIDY APPLICATION COVER NOTICE

On *F1, we talked with you about *F2 eligibility for extra help with Medicare prescription drug plan costs. We filled out the enclosed, "Application for Help with Medicare Prescription Drug Plan Costs," based on your statements. However, we cannot decide if *F3 eligible until you sign the application and give us more information.

   

Fill-Ins:

*F1-1 MMMM d, yyyy (date of interview)
*F2-1 TP:SINGLE (your or inquirer’s name (possessive))
*F3-1 Pronoun (you are/he is/she is/Client Name is) (Mapped Object)

  

INFC06

CAPTION

What You Need To Do

  

ELG025

FILING AN APPLICATION FOR MPD

  • Answer any questions circled on the application.

  • Correct any information that is wrong.

  • Sign and date the application in the space called "Your Signature." If your husband or wife is living with you, please have him or her sign in the space called "Your Spouse's Signature."

  • Mail the application to us at the address shown above in the enclosed postage paid envelope.

  

CAPC40

CAPTION

If We Don't Hear From You

  

MPD192

WHEN WE MUST RECEIVE AN APPLICATION FOR PFD

It is important that you sign the application and return it to us right away . Send it to us even if you do not have all the information. The sooner we get the signed application, the sooner we can decide if you are eligible for extra help with Medicare prescription drug plan costs. If we receive the signed application by *F1, we will use *F2, the date you contacted us, as the filing date.

   

Fill-Ins:

*F1-1 MMMM d, yyyy (60 days from date of notice (workday))
*F2-1 MMMM d, yyyy (protective filing date)


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0603092010
HI 03092.010 - UTI's for DPS - 05/07/2013
Batch run: 05/07/2013
Rev:05/07/2013