TN 30 (03-96)
NL 00703.616 SMI — Processed Declination of Coverage — Beneficiary In Current Pay Status — Refund Due
Document Identifier for Word Processor: E3616
A. EXHIBIT LETTER
This is in reference to your notice to us that you do not want to be enrolled in the medical insurance part of Medicare. A new health insurance card will be mailed to you within a few days and it will show that you have coverage only under the hospital insurance part of Medicare.
Premiums for medical insurance will not be deducted from your future benefit payments. If any premiums have been withheld from your benefit payments, they will be refunded to you in a separate check.
If you want information about enrolling for medical insurance coverage at some future date, please get in touch with any Social Security office.
B. REQUESTING INSTRUCTIONS
This notice is used to notify a beneficiary, who is in current pay status, that his/her refusal of SMI coverage has been processed. Refund of any premiums withheld will be made in a separate check.
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.