TN 30 (03-96)
NL 00703.606 SMI Refusal Request Treated As GEP Enrollment
Document Identifier on Word Processor: E3606
A. EXHIBIT LETTER
Your medical insurance coverage under title XVIII of the Social Security Act begins (1) .
We received your cancellation of your earlier request that your medical insurance coverage be terminated. Although this cancellation request was filed too late for the coverage to be reinstated without interruption, it was filed during a period in which you could reenroll. This difference is important because there are months for which you do not have medical insurance coverage.
If you believe that this determination is not correct, you may request that your case be reexamined. If you want this reconsideration, you must request it not later than 60 days from the date you receive this notice. You may make any such request through any Social Security office. If additional evidence is available, you should submit it with your request.
If you have any questions about your Medicare coverage, you should get in touch with any Social Security office. Most questions can be handled by telephone or mail. If you visit the office, please take this letter with you.
B. REQUESTING INSTRUCTIONS
Use Exhibit NL 00703.606 when a reversal request is received after a withdrawal has been processed. The reversal should be treated as a GEP enrollment if the filing date is within a GEP.
month and year the medical insurance coverage begins.
C. TYPING INSTRUCTIONS
Information for this letter will be shown on Form SSA-573. The name and address, if not given, can be taken from the latest Form SSA-3926-C2 in file.