BASIC (05-05)

HI 03094.725 Dismissal

A. Purpose/Use

A dismissal notice is sent when an appeal is dismissed. This notice is created in the Document Generation System (DGS) used in the Subsidy Appeals Unit.

B. Sample Appeal Dismissal Notice

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


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0603094725
HI 03094.725 - Dismissal - 06/20/2006