Prescription Drug Assistance
Notice of Review
Date: February 1, 2006
Social Security Number: 123-00-6789
JOHN Q. PUBLIC
123 MAIN ST
SPRINGFIELD OH 45501
Because of the report you made to us, we must review your eligibility for extra help
with Medicare prescription drug plan costs. We check to be sure that you are still
eligible and that your extra help, also known as the subsidy, is correct. We want
to make this review as simple as possible for you and without the need to visit the
office. Therefore, we are asking you to complete the same form you completed when
you applied for this extra help.
What We Will Do To Review Your Case
As part of the review, we looked at the information you told us when you applied for
the extra help with Medicare prescription drug plan costs. Your continued eligibility
is determined by the amount of your income, resources, and household size. If you
have a spouse and you are living together, your total income and resources count.
What You Need To Do For This Review
Please complete the enclosed form.
Sign and return the form in the enclosed envelope within 90 days.
Please use this form instead of using the form on our Internet website.
If This Form Is Not Returned
If this form is not returned within 90 days your help with Medicare prescription drug
plan costs will be terminated.
If you are waiting for information from another agency or need assistance, you may
call Social Security toll free at 1-800-772-1213. If you do need assistance we can
give you an additional 30 days to return the form to us.