HI 03094.020 SSA-L825 - Subsidy Application Cover Notice
The Subsidy Application Cover Notice (SSA-L825) is sent out by the field office only when an applicant insists on a “wet signature” rather than using attestation. This notice is initially available only in DPS. See HI 03010.030 for completion instructions.
B. Sample Notice SSA-L825 – Subsidy Application Cover Notice
Social Security Administration
Medicare Prescription Drug Assistance
Field Office Address
Date: December 10, 2005
Social Security Number: 123-00-6789
JOHN Q. PUBLIC
123 MAIN ST
SPRINGFIELD OH 45501
On December 10, 2005, we talked with you about your 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 you are eligible until you sign the application and give us more information.
What You Need To Do
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 or bring us the application and the information requested below along with this letter. If you mail the application and information, please use the enclosed postage paid envelope
If We Do Not Hear From You
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 February 8, 2006, we will use December 10, 2005, the date you contacted us, as the filing date.
What Will Happen
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.
If You Have Any Questions
For general questions about obtaining extra help for Medicare prescription drug plan costs, visit our website at www.socialsecurity.gov on the Internet. There you will also find the laws and regulations about the extra help.
For specific questions about your case, you may call 443-424-4423 and ask for Mary Jones. 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:
Baltimore, MD 21201
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.