Basic (05-05)

HI 03094.710 Acknowledge Receipt of Hearing

A. Purpose/Use

The “Acknowledge Receipt of Hearing” notice acknowledges receipt of a request for a telephone hearing. This notice is created in the Document Generation System (DGS) used in the Subsidy Appeals Unit.

B. Sample Acknowledgment Notice


Social Security Administration

Medicare Prescription Drug Assistance

Acknowledgment Notice


                                                                                      SDS return address

                                                                          Date: November 23, 2005

                                                                                      Social Security Number: 123-00-6789










We have received your request for a hearing by telephone of your Application for Help with Medicare Prescription Drug Plan Costs. We will send you another notice giving you the time and date of your hearing.


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, (address 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 Have Any Questions


For information about Medicare prescription drug plans or other Medicare issues, visit 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 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.




Subsidy Determination Unit Manager


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HI 03094.710 - Acknowledge Receipt of Hearing - 05/05/2008
Batch run: 07/08/2013