TN 30 (03-96)
NL 00703.617 SMI — Processed Declination of Coverage — Beneficiary In Suspense Status — Discard Any Bill For Premiums
Document Identifier for Word Processor: E3617
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.
Since our records were previously annotated to show that you were enrolled for medical insurance, a premium billing notice may have been prepared for mailing to you. If you receive a billing notice, you should destroy it.
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 suspense status, that his/her refusal of SMI coverage has been processed. Any bill for SMI premiums received should be destroyed.
C. TYPING INSTRUCTIONS
Information for this notice 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.