Prescription Drug Assistance
SDS return address
Date: November 23, 2005
JOHN Q. PUBLIC
123 MAIN ST
SPRINGFIELD OH 45501
We have received your request for a hearing by telephone on your Application for Help
with Medicare Prescription Drug Plan Costs. This letter tells you about the hearing
process and how to prepare for the hearing.
The Hearing Appointment
The time and date scheduled for your hearing is (time
The telephone number we will use to contact you for the hearing is 999-999-9999.
We will call you at this number. If it is not correct, please call us right away toll-free
at 1-800-772-1213 with the correct number.
Please be ready at least 15 minutes before the scheduled time.
Conference Call Instructions (replace
the above 3 paragraphs with
this UTI for conference calls)
You indicated on the appeal form that you will have other people present at the hearing
talking to us from more than one telephone number. We will use a telephone conference
call to conduct the hearing.
At least 15 minutes before the scheduled time, all participants must call us at this
number: 1-800-123-4567. The pass code for the call is 9999. We will begin the hearing
when everyone has called in.
About the Hearing
During the call, we will discuss (hearing
The hearing is your chance to show that the issues should be decided in your favor.
Therefore, we need to make sure that your file has everything you want us to consider.
You are responsible for submitting any additional evidence. After we review the evidence
in the file, we may ask for more evidence to consider at the hearing. You can have
a lawyer, friend, or other party present at the telephone hearing. You may ask us
to issue a subpoena that requires a person to submit documents or testify at your
We will make a decision based on the information in the file and any additional information
Providing Additional Information
If there is more information you want us to see, please send it to us within 10 days
from the date of this notice. You can mail the information to Social Security Administration,
to be determined) or you can call us at (special
800#). If you need help, you should contact us immediately.
You May See The Information In Your File
If you wish to see the information in your file, you may do so before the date of
the review of your case. If you wish to review the file, please call us toll-free
at (phone number of SAU).
If You Want To Reschedule Or Change Phone Numbers
If you cannot be present at the time of the hearing, please call us to reschedule.
If you change your phone number, you need to notify us right away at (special 800#). If you do not reschedule and are not present at the time of the hearing, we will
make a decision based solely on the information currently in your file.
When You Will Receive a Decision
We will send another notice when we make a decision on the issue(s).
If You Have Any Questions
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.
Determination Unit Manager