Social Security
Administration
Medicare
Prescription Drug Assistance
Notice of
Appeal Dismissal
SDS return address
Date: November 23,
2005
Social Security Number:
123-00-6789
JOHN Q. PUBLIC
123 MAIN ST
SPRINGFIELD OH 45501
This is about your request for review of your Application for Help with Medicare Prescription
Drug Plan Costs determination dated October 12, 2005.
We Have Denied your Request for Review
(Reason for dismissal)
This Decision Is Final
This decision is our final decision, and it is not subject to any further administrative
review by us.
If You Disagree With The Dismissal
We may vacate a dismissal of your request for administrative review, if within 60
days after you receive this notice, you request that the dismissal be vacated and
show good cause why the request should not be dismissed.
How To Sign Up For A Medicare Prescription
Drug Plan
You do not need to receive this extra help paying for the costs related to your Medicare
prescription drug plan in order to be eligible to enroll in a Medicare prescription
drug plan or Medicare Advantage drug plan. You can enroll beginning November 15, 2005.
For more information about the prescription drug plans available in your area, go
to 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.
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.
Subsidy Determination
Reviewer